Inspired by four recent adverse event reports related to needling.[1–4]
PMCT – post-mortem computed tomographykey to acronyms
ED – emergency department
CT – computed tomography
CXR – chest x ray
DSA – digital subtraction angiography
TAE – transcatheter arterial embolization
AEs – adverse events
DED – dry eye disease
This week I have a series of recent adverse events to report with some quite dramatic images to present at the linked webinar.
The first is not acupuncture-related as such since it involves self-needling with a rather large bore needle used for body piercing. This report comes from the Office of the Chief Medical Examiner in Baltimore and is published in a journal called Academic Forensic Pathology. So, you should have guessed by now that it involves a fatality. We have come across the use of PMCT twice before in this blog in Fatal Bilateral Pneumothoraces and Another Fatality. In this case the history included the quote “needle went in all the way”, so PMCT was the obvious choice of preliminary examination. The needle was a 14-gauge piercing needle of 2 inches length. It did not have a hub or handle, so there was nothing to stop the blunt end sliding through the skin, which is apparently what happened in this rather obese 33-year-old man. The skin would have then closed over the end of the needle meaning it would have been impossible to remove, and any attempt to do so would have resulted in the needle penetrating deeper. The unfortunate man died relatively rapidly and surely his untimely end must qualify him for consideration in the Darwin Awards.
The Darwin Awards were first described as “…given posthumously to people who have made the supreme sacrifice to keep their genes out of our pool.” However, the current website leads with:
Honouring Charles Darwin, the father of evolution, Darwin Awards commemorate those who improve our gene pool – by removing themselves from it in the most spectacular way possible.
Whilst perusing the references of this case report, I came across one with acupuncture in the title from 2016 in the European Heart Journal. It was not one I had seen before, it comes from Bern, and it justifies a mention. A 51-year-old female was referred to the ED with chest pain and dyspnoea. She got as far as angiography before a needle was seen. Subsequent CT imaging demonstrated a needle-shaped radio-opaque object perforating the left ventricle and reaching the lower lobe of the left lung. On discussing these findings with the patient, she immediately mentioned an acupuncture treatment performed some days before by a non-professional who was a close friend. A 0.20x75mm needle was successfully removed and a left haemothorax drained at open cardiac surgery without the need for cardiopulmonary bypass.
The next one is from Tokyo. It is a case of massive haemothorax in an otherwise healthy 36-year-old woman who had acupuncture treatment the previous day (14 hours prior to admission) for muscle pain (left side dorsal back). CXR on admission showed a massive left pleural effusion (a white out), and a left-sided chest drain collected 1300ml of blood in the first 90 minutes. Contrast enhanced CT showed a massive left haemothorax with contrast leakage into the left thoracic cavity. DSA demonstrated active bleeding from the second intercostal artery, and this was successfully embolised via the costocervical artery during the TAE procedure. Residual haematoma was cleared via thoracoscopy, and the patient was discharged one week later. Follow-up at 6 months showed no rebleeding.
Whilst we are familiar with pneumothorax as a complication of acupuncture, this case does not mention lung injury, so it is possible that the acupuncture needle only reached as far as the second intercostal artery and parietal pleura. Clearly the needle was too deep since the intercostal neurovascular bundles lie just inside the lower edge of each rib. Under most circumstances we would expect that arterial puncture with an acupuncture needle would be limited, but I guess there was no natural tamponade due to the proximity of the thoracic cavity. Presumably there is an element of bad luck here, but it is a salutary lesson, all the same, to those of us who needle deep onto ribs.
Next, we have a case of acupuncture-associated infection with anaerobic bacteria (Clostridium species and Mycobacterium massiliense) and a fungal species (Scedosporium) in a patient who subsequently developed tetanus. The report comes from Thailand and there is limited detail on the circumstances of the acupuncture; however, imaging clearly demonstrates an appearance consistent with multiple subcutaneous needle fragments. I will show the images at the webinar, but the case itself is of limited use to acupuncturists. I am sure it is of more interest to the microbiologists.
The last of these recent adverse event reports is an image in JAMA Ophthalmology. It is a photograph of an optic fundus showing a retinal tear with vitreous haemorrhage. The image was captured 3 days after orbital acupuncture for ear disease, during which time the patient had suffered a decline in vision and floaters in her left eye.
Personally, I have never felt the need to needle into the orbit, and having trained and worked alongside an ophthalmic surgeon, I am certainly not disposed to do so lightly. I published a blog on Ocular AEs exactly a year ago today… perhaps that is synchronicity?
With that you might have thought it was all over but wait… a trial published within the last week compared acupuncture with artificial tears in 120 patients with moderate to severe dry eye disease (DED). The acupuncture involved brief, but rather vigorous needling at BL1. A 0.30x40mm needle was inserted, removed, and reinserted repeatedly at BL1 until ‘tears flowed freely from the eye’. Treatment was performed 3 times a week for 8 weeks. That is roughly 100 needle insertions per eye per patient over the course of the trial.
The results of the trial were in favour of the acupuncture and no ocular AEs occurred, but I don’t think this will convince me to add this technique to my acupuncture repertoire.
1 Ali Z, Mourtzinos N. Postmortem Imaging of an Unusual Case of Fatal Heart and Lung Perforation Due to Self-Treatment. Acad Forensic Pathol 2022;12:75–9. doi:10.1177/19253621221102045
2 Hanabusa Y, Kubo T, Watadani T, et al. Successful transcatheter arterial embolization for a massive hemothorax caused by acupuncture. Radiol Case Rep 2022;17:3107–10. doi:10.1016/j.radcr.2022.05.040
3 Prasoppokakorn T. Acupuncture-Associated Mycobacterium massiliense and Scedosporium Infections Superimposed by Tetanus. Case Rep Infect Dis 2022;2022:8918020. doi:10.1155/2022/8918020
4 Wu P, Li N, Gao L. Inadvertent Ocular Perforation Caused by Traditional Acupuncture. JAMA Ophthalmol 2022;140:e221823. doi:10.1001/jamaophthalmol.2022.1823
5 Wigger O, Stortecky S, Most H, et al. Cardiac perforation as a rare complication of acupuncture. Eur Heart J 2016;37:1383. doi:10.1093/eurheartj/ehv171
6 Zhang X, Zhang B, Peng S, et al. Effectiveness of acupuncture at acupoint BL1 (Jingming) in comparison with artificial tears for moderate to severe dry eye disease: a randomized controlled trial. Trials 2022;23:605. doi:10.1186/s13063-022-06486-4