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\begin{document}

\title{Penetrating Thorn in the Heart Complicated by Infective Endocarditis}



\author[1]{Salah Eldin M.  Hassan}%
\author[2]{Mohamed A.  Ahmed}%
\author[1]{Sabir T.  Hussein}%
\author[1]{Abdallah E.  Elsheikh}%
\author[3]{ Moh. Eljack}%
\author[4]{Mazin S. Hassan Haroun}%
\author[4]{Khabab  Mohamed Ahmed}%
\author[5]{Mohammed Omer}%
\author[4]{Ghassan Elfatih}%
\affil[1]{Medani Heart Diseases and Surgery Center}%
\affil[2]{Medani Heart Diseases and Surgery}%
\affil[3]{Wad Medani center For heart disease and Surgery }%
\affil[4]{University of Khartoum Faculty of Medicine}%
\affil[5]{University of Gadarif Faculty of Medicine and Health Science}%


\vspace{-1em}



  
  \date{June 14, 2024}


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\selectlanguage{english}
\begin{abstract}
A 3 years old child presented with recurrent chest pain for 3 months,
echocardiography showed a thorn inside left ventricle, patient diagnosed
as foreign body plus infective endocarditis, received proper treatment,
and operation done after inflammatory reaction subsided.%
\end{abstract}%



\sloppy


\textbf{Penetrating Thorn in the Heart Complicated by Infective
Endocarditis}

Salah Eldin M.E.Hassan\textsuperscript{1}, Mohamed Alamin
Ahmed\textsuperscript{2}, Sabir Taha Hussein\textsuperscript{3},
Abdallah Elamin Elsheikh\textsuperscript{4}, Moh.Mah.Fadel
Alla.Eljack\textsuperscript{5}, Mazin Salah-Eldien Hassan
Haroun\textsuperscript{6}, Khabab Abbasher Hussien Mohamed
Ahmed\textsuperscript{7} Mohammed Eltahier Abdalla Omer
\textsuperscript{8}, Ghassan Elfatih
Mustafa\textsuperscript{9\textbf{*}}

\begin{enumerate}
\tightlist
\item
  MD, Department of Cardiothoracic Surgery\_Medani Heart Diseases and
  Surgery Center, Sudan ,\emph{doctorsalaheart@gmail.com}
\item
  MD, Department of Pediatric Cardiology \_Medani Heart Diseases and
  Surgery Center , Sudan ,\emph{Mohamedelsuni11@gmail.com}
\item
  EBCTS, Department of Cardiothoracic Surgery \_Medani Heart diseases
  and Surgery Center , Sudan ,\emph{saberharaz76@gmail.com}
\item
  FRCSI, Department of Cardiothoracic Surgery\_ Medani Heart Diseases
  and Surgery Center, Sudan ,\emph{namarsa@hotmail.com}
\item
  MBBS UNIVERSITY OF BAKHT ALRUDA, Medical Doctor At Medani Heart
  Diseases and Surgery Center, Sudan ,\emph{m.mahmmoud96@gmail.com}
\item
  Medical student, University of Khartoum, Faculty of Medicine,
  Sudan\emph{mazinsalaheldien@gmail.com}
\item
  Medical student, University of Khartoum, Faculty of Medicine,
  Khartoum, Sudan, ORCID:
  0000-0003-4608-5321,\emph{Khabab9722@gmail.com}
\item
  Teaching Assistant ,Medicine department , Gadarif University Faculty
  of Medicine and Health Sciences,
  Sudan\emph{Mohammedeltahier100@gmail.com}
\item
  Medical student, University of Khartoum, Faculty of Medicine,
  Khartoum, Sudan,\emph{nimirghassan@gmail.com}
\end{enumerate}

\textbf{Correspondence Author:}

Ghassan Elfatih Mustafa

Email: nimirghassan@gmail.com, Sudan, 11111

\textbf{Abstract}

A 3 years old child presented with recurrent chest pain for 3 months,
echocardiography showed a thorn inside left ventricle, patient diagnosed
as foreign body plus infective endocarditis, received proper treatment,
and operation done after inflammatory reaction subsided.

\textbf{Key words:}

Foreign Body, Thorn, echocardiography, infective endocarditis,
Cardiopulmonary bypass.

\textbf{Introduction:}

A foreign body can enter the heart either directly through a penetrating
trauma or through migration of a distal fragment from peripheral
vessels; however All of this events are considered to be of very rare
occurrence with possible complications to occurs include infective
endocarditis, cardiac tamponade and pneumothorax(1,2). Infective
endocarditis (IE) is a cardiac infection that affects the endothelium.
It has an annual incidence of 3--10 per 100,000 people, with a fatality
rate of up to 30\% after 30 days. Because of the variety of causative
microorganisms, underlying cardiac diseases, and pre-existing
comorbidities, the clinical presentation of IE is exceedingly diverse.
It can appear as an acute, subacute, or chronic condition (6).

Our case is considered to be the first case documented worldwide of a
penetrating thorn in the heart that's complicated with infective
endocarditis for which it was first treated medically and then removed
through cardiopulmonary bypass surgery.

\textbf{Case Report:}

A 3 years old child of average body mass index and normal developmental
milestones with history of falling down on his abdomen was referred to
paediatric cardiology department with recurrent chest pain for 3 months
that was not managed by seeking many medical experts. X-ray revealed
nothing and he was treated by simple analgesia. Echocardiography showed
a thorn within the left ventricle that's penetrating from the apex
posteriorly covered by big clot anteriorly that measures (15cm \selectlanguage{ngerman}× 11cm)
and was diagnosed as foreign body that was complicated by infective
endocarditis (\textbf{Figure 1} ). The patients was put on the medical
treatment of infective endocarditis according to the international
regimen for 2 to 3 weeks, followed by inflammatory markers follow-up and
then he was shifted to operation room to undergo median sternotomy which
showed normal pericardium apart from adhesions between chest and
diaphragm. The patient was put on by pass after we arrest the heart;
adhesions were removed completely then they revealed the definitive body
(\textbf{Figure 2} ), foreign body reaction and a whole of a big slider
thorn come out. We went into trans-atrial approach through left atrium
and then through mitral valve with organized thrombus, we washed with
antibiotic solution, we checked that's mitral valve is normal then we
closed. Tricuspid valve was tested and was found to be normal so right
atrium was closed. We debride the place of foreign body entry, then we
closed using pericardium strips of two layers warmed and separated.
Haemostasis was secured and the chest was closed with two chest tubes.
Patient was sent to paediatric ICU under cover of broad spectrum
antibiotics, antifungal and analgesia on need. Child was extubated
successfully on the next day and was followed-up for 1 week clinically,
with laboratory markers and then was sent home after Echo was done on
the day of discharged which showed completely normal heart. The patient
was told to be seen on refer clinic after 1 month of discharge.

\textbf{Discussion}

Penetrating cardiac injury in childhood is extremely rare. The objects
usually are needles, bullets, grenade acupuncture or sometimes sewing
needles (3). In our case, the patient had symptoms of infective
endocarditis. What's surprising is there was no cardiac tamponade after
trauma as we assume blood drained to the left pleural cavity. This is an
unusual case in that the thorn directly caused infective endocarditis.
The thorn was embedded in the left ventricle, penetrating from the apex
posteriorly. As it settled there, it was covered by a big clot
anteriorly and adhesions formed. Management for such cases is very
difficult and case dependent. As data concerning foreign bodies in the
heart is limited, hence no specific accredited guidelines or
recommendations are available. In symptom-free patients, surgery depends
on the type and place of the foreign body. Patients having foreign
bodies completely embedded or in the pericardial space or in the
myocardium usually remained asymptomatic for a while (4). The surgical
approach for removing the foreign body is individualized according to
the type of foreign body (5). Our patient was overall stable, so first
we focused on treating infective endocarditis to prevent life-long
complications, and to make sure the patient is in the best possible
condition for the surgery. Although the risk was high, surgery with
bypass was indicated to avoid a life -threatening situation. Possible
complications for such cases vary, and all are life threatening if the
patient is left untreated. Infective endocarditis and the presence of a
foreign body in the heart both contribute to thrombosis and then fatal
embolization. Also the foreign body can cause injury to the surrounding
vessels, and heart rhythm can be disturbed (3).

To our knowledge and recent literature, this is the first case with such
a presentation of a thorn with this measurement that is complicated by
infective endocarditis.

\textbf{Conclusion:}

Foreign bodies in the heart are rare but have high mortality and
morbidity rates. Proper investigations (such as echocardiogram), proper
treatment for infection, and accurate timing for surgery are keys for
patient survival.

\textbf{Declaration section:-}

\textbf{Conflicts of interest:}

All authors declare that there are no conflicts of interest.

\textbf{Funding:}

There was no fund.

\textbf{Informed consents:}

Considering the child was 3 years old both written and verbal consents
were taken from his guardians (parents) in accordance with the general
preoperative guidelines as well as consent to be the case of interest in
this article.

\textbf{Ethical approval;}

Ethical approval was obtained from the Sudan State Ministry of Health.

\textbf{Authors' contributions}

All authors participated in planning the study, data collection, results
and discussion sections.

\textbf{Acknowledgements}

Not applicable\textbf{.}

\par\null

\textbf{References:}

1. Dato A, Filosso PL. Report of fourteen cases and review of the
literature. 2003;(August).

2. Darmawan H. An Unusual Foreign Body in the Heart\selectlanguage{english} : A Case Report.
2018;24(4):205--7.

3. Supomo, Darmawan H. An unusual foreign body in the heart: A case
report. Ann Thorac Cardiovasc Surg. 2018;24(4):205--7.

4. Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE. Cardiac missiles. A
review of the literature and personal experience. Ann Surg.
1990;211(5):639--48.

5. Fry SJ, Picard MH, Tseng JF, Briggs SM, Isselbacher EM. The
echocardiographic diagnosis, characterization, and extraction guidance
of cardiac foreign bodies. J Am Soc Echocardiogr. 2000 Mar;13(3):232-9.
doi: 10.1067/mje.2000.102984. PMID: 10708473.

6. Rajani R, Klein J. Infective endocarditis: A contemporary update.
Clinical

Medicine. 2020;20(1):31-35.\selectlanguage{english}
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