ILLUSTRATIVE CASE
Unusual Sequela From a Pencil Stab Wound Reveals a Retained Graphite Foreign Body Iris A. Seitz, MD, PhD,* Bradley A. Silva, JD,† and Loren S. Schechter, MD* Abstract: Penetrating pencil-tip injuries are common among children and usually resolve without long-term sequelae. However, failure to detect and remove embedded pencil fragments can result in increased morbidity or misdiagnoses of other, more serious, conditions. We report on the case of a 10-year-old boy stabbed with a pencil on his right chin. Initial treatment in the emergency department included irrigation and closure of the laceration. Following suture removal, the patient returned to the emergency department (with bright-purple drainage from the wound site). Radiographic evaluation led to the discovery of an embedded foreign body requiring surgical removal. Key Words: pencil stab wound, graphite, foreign-body granuloma, foreign-body reaction, open wound (Pediatr Emer Care 2014;30: 568–570)
P
enetrating trauma caused by a pencil is common among children. Reported injuries from pencil-tip trauma include lung,1,2 intracranial,3 osteomyelitis of the femur,4 diaphragmatic,5 intraorbital,6 pharyngeal,7 and perineal8 injuries. Although most injuries are minor, a delay in diagnosis and treatment can lead to serious complications. As described in this report, the etiology of diagnostic delays may be multifactorial. For example, children may be afraid of punishment from parents or teachers. In addition, initial physical examination may fail to reveal a foreign body that is deeply embedded. Additional diagnostic imaging, such as plain films, computed tomography (CT), or ultrasonography, may be required. We report on a case of facial laceration secondary to penetrating trauma from a pencil. The child’s unusual presentation ultimately led to the discovery of a retained graphite foreign body.
FIGURE 1. Photograph of patient’s chin showing the wound with purple drainage at first office visit.
mandible (Fig. 2). The patient was scheduled for surgical removal of the retained foreign body. Under general anesthesia, blunt dissection with a hemostat followed the track of the foreign body. Thick, bright-purple drainage was encountered (Fig. 3). The foreign body, measuring approximately 1 cm, was identified and removed. It appeared consistent with a degrading pencil tip (Fig. 4). The wound was debrided of residual purple-stained tissue and several smaller fragments of foreign material. Intraoperative fluoroscopy and manual palpation of the wound were used to confirm removal of foreign material. The wound was irrigated and closed in a layered fashion. Cytology showed mixed inflammatory cells, and subsequent histology demonstrated granuloma formation and granulating subcutaneous tissue with necrosis (Fig. 5). The sutures were removed on postoperative day 7, and the patient healed uneventfully. At 6 months’ follow-up, the patient is asymptomatic, without residual pain or inflammation (Fig. 6).
CASE A 10-year-old boy presented to the emergency department (ED) with a laceration on the right side of his chin after being stabbed with a wooden, noncolored pencil. The wound was cleaned, irrigated, and sutured. The patient returned to the ED on day 10 for suture removal. Physical examination revealed mild induration around the wound. A few days later, the patient returned to the ED with tenderness and bright-purple drainage from the wound (Fig. 1). The patient was referred for plastic surgery evaluation. Physical examination revealed a 1-cm wound with thick, bright-purple drainage. There was mild induration and swelling without erythema. A facial CT scan was ordered, and the wound was treated with topical antimicrobial ointment. The CT scan revealed a deep retained foreign body along the right side of the From the *University Plastic Surgery, Affiliated With †Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL. Disclosure: The authors declare no conflict of interest. Reprints: Iris A. Seitz, MD, PhD, Research and International Collaboration, University Plastic Surgery, 9000 Waukegan Rd, Suite 210, Morton Grove, IL 60053 (e‐mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
568
www.pec-online.com
DISCUSSION Delay in diagnosis and treatment of a graphite foreign body can lead to undesirable reactions, such as local pain and inflammation, infection, abscess formation, skin pigmentation, and graphite foreign-body reaction. “Pencil graphite,” or rather the core of a
FIGURE 2. Computed tomography scan of the head showing a foreign body embedded superior and posterior to the mental foramen, right mandibular body. Pediatric Emergency Care • Volume 30, Number 8, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 30, Number 8, August 2014
FIGURE 3. Intraoperative photograph of purple wound drainage.
pencil, is composed of 3 main components. The composition of this core varies dependent on the manufacturer and the type/ number of the pencil. The softer and darker the pencil, the higher the percentage of graphite in relation to clay. Graphite (elemental carbon in its solid state, Cs) accounts for anywhere from 41% to 90%, clay (aluminum silicate) 4% to 53%, and paraffin wax 5% to 8%.9,10 These materials and other trace chemicals are not inert and, along with retained wood from the pencil, can be proinflammatory. Furthermore, they are not sterile and can harbor bacteria, leading to infection.5,11 In addition to acute complications, long-term sequelae can also occur. Each component of the graphite core can cause a foreign-body reaction. Paraffin can induce a nonallergic reaction, whereas both silica and graphite can cause granulomatous reactions.9 Graphite and silica granulomas have been reported to have delayed reactions ranging from 1.5 to 58 years between injury and granuloma formation.9 It has been speculated that this delay is based on the time required for the material to break down and become dispersed within the interstitium.9 These delayed granulomatous reactions are of particular significance because they can be misdiagnosed as more serious diseases. For instance, the clinical and histologic appearance of a foreign-body granuloma can resemble a sarcoma12 or melanoma.13 If a patient does not report a history of penetrating trauma, both a delay and misdiagnosis can occur. In this report, the unusual purple color of the wound drainage coupled with delayed presentation suggested the presence of a retained foreign body. Based on the cytology and histology, the diagnosis was a chronic, inflammatory process in response to the foreign body. However, the bright-purple drainage, resulting from a noncolored wooden pencil fragment retained in the wound, is not easily explained. A review of the literature focusing on pencil injuries failed to reveal such a phenomenon. However, when redirecting the search toward additional chemicals in noncolored graphite pencils that could cause such purple coloration, we found that certain trace chemicals can induce such an effect. Interestingly,
FIGURE 4. Intraoperative photograph of pencil tip after removal. © 2014 Lippincott Williams & Wilkins
Retained Graphite Foreign Body
FIGURE 5. Histologic evaluation showing skin with foci of chronic inflammation (hematoxylin-eosin stain).
a coal-tar by-product aniline contained in indelible/copying pencils, manufactured as far back as 1870, releases a bright-purple dye when brought in contact with water or alcohol. Aniline and its derivatives were added to the composition of a regular graphite pencil to confer indelible qualities. The indelible/copying pencil has a similar appearance as a regular graphite pencil and in fact when written on paper can be distinguished from ordinary graphite pencil only by analysis under the microscope or various wet test conditions.14 We hypothesize that the bright-purple color is due to a reaction of the embedded pencil fragment possibly containing trace elements of aniline, which when hydrated by the surrounding tissue elutes the purple dye, thereby giving the drainage its strange hue. Large amounts of purple drainage persisted over a 2-week period, while the occult, embedded pencil tip was degrading prior to surgical removal.
SUMMARY Early diagnosis and treatment of a penetrating trauma caused by a pencil may prevent prolonged wound infection and sequelae. Presentation contemporaneous with the trauma is important to alert the physician to the possibility of a retained foreign body. As described above, misdiagnosis is more likely if the time between presentation and injury is delayed. Even if presentation is immediate, however, the foreign body may be too deep to palpate or visualize.10 In such cases, radiographic imaging can provide assistance in diagnosis and localization. Plain films or CT can be used to view radiopaque material such as pencil graphite, whereas ultrasonography can be used to view radiolucent objects such as pencil wood.10
FIGURE 6. Photograph of patient 6 months after surgical removal of graphite foreign body. www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
569
Pediatric Emergency Care • Volume 30, Number 8, August 2014
Seitz et al
REFERENCES 1. Hoffman D, Sharieff G. Pencil stab wound results in pneumonia and pleural effusion. Am J Emerg Med. 2000;18:345–346. 2. Singh RS, Dhaliwal RS, Behera D. Unusual intraperitoneal foreign body: a pencil. Indian J Chest Dis Allied Sci. 1998;40:65–67. 3. Inbasekaran V, Jawahar G, Natarajan M. Brain abscess caused by pencil tip injury. J Indian Med Assoc. 1985;83:284. 4. Volpin G, Kleinhaus U, Berant M, et al. Osteomyelitis of the femoral neck caused by a pencil stab wound. Eur J Pediatr Surg. 1992;2:122–124.
8. Kenigsberg K, Ashley R, DiCarmine F. Unusual injury caused by a pencil. J Pediatr Surg. 1995;30:891–892. 9. Terasawa N, Kishimoto S, Kibe Y, et al. Graphite foreign body granuloma. Br J Dermatol. 1999;141:774–776. 10. Staedtler Product Information. http://wiki.answers.com/Q/ What_is_the_chemical_composition_and_formula_for_pencil_lead. 11. Halaas GW. Management of foreign bodies in the skin. Am Fam Physician. 2007;76:683–688.
5. Singal AK, Jindal B, Bhatnager V. Penetrating diaphragmatic injury caused by a pencil. J Indian Assoc Pediatr Surg. 2005;10:112–113.
12. Ando A, Hatori M, Hagiwara Y, et al. Imaging features of foreign body granuloma in the lower extremities mimicking a soft tissue neoplasm. Ups J Med Sci. 2009;114:46–51.
6. Herman TE, Shackelford GD, Tychsen L. Unrecognized retention of intraorbital graphite pencil fragments: the role of computerized tomography. Pediatr Radiol. 1995;25:535–537.
13. Gormley RH, Kovach SJ, Zhang PJ. Role for trauma in inducing pencil “lead” granuloma in skin. J Am Acad Dermatol. 2010;62:1074–1075.
7. Smyth D, Fenton J, Tunion G, et al. Occult pharyngeal perforation secondary to pencil injury. J Laryngol Otol. 1996;110:901–903.
14. Dube Liz. The copying pencil: composition, history, and conservation implications. Book Pap Group Annu. 1998;17:45–52.
570
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© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Unusual Sequela From a Pencil Stab Wound Reveals a Retained Graphite Foreign Body Iris A. Seitz, MD, PhD,* Bradley A. Silva, JD,† and Loren S. Schechter, MD* Abstract: Penetrating pencil-tip injuries are common among children and usually resolve without long-term sequelae. However, failure to detect and remove embedded pencil fragments can result in increased morbidity or misdiagnoses of other, more serious, conditions. We report on the case of a 10-year-old boy stabbed with a pencil on his right chin. Initial treatment in the emergency department included irrigation and closure of the laceration. Following suture removal, the patient returned to the emergency department (with bright-purple drainage from the wound site). Radiographic evaluation led to the discovery of an embedded foreign body requiring surgical removal. Key Words: pencil stab wound, graphite, foreign-body granuloma, foreign-body reaction, open wound (Pediatr Emer Care 2014;30: 568–570)
P
enetrating trauma caused by a pencil is common among children. Reported injuries from pencil-tip trauma include lung,1,2 intracranial,3 osteomyelitis of the femur,4 diaphragmatic,5 intraorbital,6 pharyngeal,7 and perineal8 injuries. Although most injuries are minor, a delay in diagnosis and treatment can lead to serious complications. As described in this report, the etiology of diagnostic delays may be multifactorial. For example, children may be afraid of punishment from parents or teachers. In addition, initial physical examination may fail to reveal a foreign body that is deeply embedded. Additional diagnostic imaging, such as plain films, computed tomography (CT), or ultrasonography, may be required. We report on a case of facial laceration secondary to penetrating trauma from a pencil. The child’s unusual presentation ultimately led to the discovery of a retained graphite foreign body.
FIGURE 1. Photograph of patient’s chin showing the wound with purple drainage at first office visit.
mandible (Fig. 2). The patient was scheduled for surgical removal of the retained foreign body. Under general anesthesia, blunt dissection with a hemostat followed the track of the foreign body. Thick, bright-purple drainage was encountered (Fig. 3). The foreign body, measuring approximately 1 cm, was identified and removed. It appeared consistent with a degrading pencil tip (Fig. 4). The wound was debrided of residual purple-stained tissue and several smaller fragments of foreign material. Intraoperative fluoroscopy and manual palpation of the wound were used to confirm removal of foreign material. The wound was irrigated and closed in a layered fashion. Cytology showed mixed inflammatory cells, and subsequent histology demonstrated granuloma formation and granulating subcutaneous tissue with necrosis (Fig. 5). The sutures were removed on postoperative day 7, and the patient healed uneventfully. At 6 months’ follow-up, the patient is asymptomatic, without residual pain or inflammation (Fig. 6).
CASE A 10-year-old boy presented to the emergency department (ED) with a laceration on the right side of his chin after being stabbed with a wooden, noncolored pencil. The wound was cleaned, irrigated, and sutured. The patient returned to the ED on day 10 for suture removal. Physical examination revealed mild induration around the wound. A few days later, the patient returned to the ED with tenderness and bright-purple drainage from the wound (Fig. 1). The patient was referred for plastic surgery evaluation. Physical examination revealed a 1-cm wound with thick, bright-purple drainage. There was mild induration and swelling without erythema. A facial CT scan was ordered, and the wound was treated with topical antimicrobial ointment. The CT scan revealed a deep retained foreign body along the right side of the From the *University Plastic Surgery, Affiliated With †Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL. Disclosure: The authors declare no conflict of interest. Reprints: Iris A. Seitz, MD, PhD, Research and International Collaboration, University Plastic Surgery, 9000 Waukegan Rd, Suite 210, Morton Grove, IL 60053 (e‐mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
568
www.pec-online.com
DISCUSSION Delay in diagnosis and treatment of a graphite foreign body can lead to undesirable reactions, such as local pain and inflammation, infection, abscess formation, skin pigmentation, and graphite foreign-body reaction. “Pencil graphite,” or rather the core of a
FIGURE 2. Computed tomography scan of the head showing a foreign body embedded superior and posterior to the mental foramen, right mandibular body. Pediatric Emergency Care • Volume 30, Number 8, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 30, Number 8, August 2014
FIGURE 3. Intraoperative photograph of purple wound drainage.
pencil, is composed of 3 main components. The composition of this core varies dependent on the manufacturer and the type/ number of the pencil. The softer and darker the pencil, the higher the percentage of graphite in relation to clay. Graphite (elemental carbon in its solid state, Cs) accounts for anywhere from 41% to 90%, clay (aluminum silicate) 4% to 53%, and paraffin wax 5% to 8%.9,10 These materials and other trace chemicals are not inert and, along with retained wood from the pencil, can be proinflammatory. Furthermore, they are not sterile and can harbor bacteria, leading to infection.5,11 In addition to acute complications, long-term sequelae can also occur. Each component of the graphite core can cause a foreign-body reaction. Paraffin can induce a nonallergic reaction, whereas both silica and graphite can cause granulomatous reactions.9 Graphite and silica granulomas have been reported to have delayed reactions ranging from 1.5 to 58 years between injury and granuloma formation.9 It has been speculated that this delay is based on the time required for the material to break down and become dispersed within the interstitium.9 These delayed granulomatous reactions are of particular significance because they can be misdiagnosed as more serious diseases. For instance, the clinical and histologic appearance of a foreign-body granuloma can resemble a sarcoma12 or melanoma.13 If a patient does not report a history of penetrating trauma, both a delay and misdiagnosis can occur. In this report, the unusual purple color of the wound drainage coupled with delayed presentation suggested the presence of a retained foreign body. Based on the cytology and histology, the diagnosis was a chronic, inflammatory process in response to the foreign body. However, the bright-purple drainage, resulting from a noncolored wooden pencil fragment retained in the wound, is not easily explained. A review of the literature focusing on pencil injuries failed to reveal such a phenomenon. However, when redirecting the search toward additional chemicals in noncolored graphite pencils that could cause such purple coloration, we found that certain trace chemicals can induce such an effect. Interestingly,
FIGURE 4. Intraoperative photograph of pencil tip after removal. © 2014 Lippincott Williams & Wilkins
Retained Graphite Foreign Body
FIGURE 5. Histologic evaluation showing skin with foci of chronic inflammation (hematoxylin-eosin stain).
a coal-tar by-product aniline contained in indelible/copying pencils, manufactured as far back as 1870, releases a bright-purple dye when brought in contact with water or alcohol. Aniline and its derivatives were added to the composition of a regular graphite pencil to confer indelible qualities. The indelible/copying pencil has a similar appearance as a regular graphite pencil and in fact when written on paper can be distinguished from ordinary graphite pencil only by analysis under the microscope or various wet test conditions.14 We hypothesize that the bright-purple color is due to a reaction of the embedded pencil fragment possibly containing trace elements of aniline, which when hydrated by the surrounding tissue elutes the purple dye, thereby giving the drainage its strange hue. Large amounts of purple drainage persisted over a 2-week period, while the occult, embedded pencil tip was degrading prior to surgical removal.
SUMMARY Early diagnosis and treatment of a penetrating trauma caused by a pencil may prevent prolonged wound infection and sequelae. Presentation contemporaneous with the trauma is important to alert the physician to the possibility of a retained foreign body. As described above, misdiagnosis is more likely if the time between presentation and injury is delayed. Even if presentation is immediate, however, the foreign body may be too deep to palpate or visualize.10 In such cases, radiographic imaging can provide assistance in diagnosis and localization. Plain films or CT can be used to view radiopaque material such as pencil graphite, whereas ultrasonography can be used to view radiolucent objects such as pencil wood.10
FIGURE 6. Photograph of patient 6 months after surgical removal of graphite foreign body. www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
569
Pediatric Emergency Care • Volume 30, Number 8, August 2014
Seitz et al
REFERENCES 1. Hoffman D, Sharieff G. Pencil stab wound results in pneumonia and pleural effusion. Am J Emerg Med. 2000;18:345–346. 2. Singh RS, Dhaliwal RS, Behera D. Unusual intraperitoneal foreign body: a pencil. Indian J Chest Dis Allied Sci. 1998;40:65–67. 3. Inbasekaran V, Jawahar G, Natarajan M. Brain abscess caused by pencil tip injury. J Indian Med Assoc. 1985;83:284. 4. Volpin G, Kleinhaus U, Berant M, et al. Osteomyelitis of the femoral neck caused by a pencil stab wound. Eur J Pediatr Surg. 1992;2:122–124.
8. Kenigsberg K, Ashley R, DiCarmine F. Unusual injury caused by a pencil. J Pediatr Surg. 1995;30:891–892. 9. Terasawa N, Kishimoto S, Kibe Y, et al. Graphite foreign body granuloma. Br J Dermatol. 1999;141:774–776. 10. Staedtler Product Information. http://wiki.answers.com/Q/ What_is_the_chemical_composition_and_formula_for_pencil_lead. 11. Halaas GW. Management of foreign bodies in the skin. Am Fam Physician. 2007;76:683–688.
5. Singal AK, Jindal B, Bhatnager V. Penetrating diaphragmatic injury caused by a pencil. J Indian Assoc Pediatr Surg. 2005;10:112–113.
12. Ando A, Hatori M, Hagiwara Y, et al. Imaging features of foreign body granuloma in the lower extremities mimicking a soft tissue neoplasm. Ups J Med Sci. 2009;114:46–51.
6. Herman TE, Shackelford GD, Tychsen L. Unrecognized retention of intraorbital graphite pencil fragments: the role of computerized tomography. Pediatr Radiol. 1995;25:535–537.
13. Gormley RH, Kovach SJ, Zhang PJ. Role for trauma in inducing pencil “lead” granuloma in skin. J Am Acad Dermatol. 2010;62:1074–1075.
7. Smyth D, Fenton J, Tunion G, et al. Occult pharyngeal perforation secondary to pencil injury. J Laryngol Otol. 1996;110:901–903.
14. Dube Liz. The copying pencil: composition, history, and conservation implications. Book Pap Group Annu. 1998;17:45–52.
570
www.pec-online.com
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
