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CASE LETTER
Year : 2021  |  Volume : 38  |  Issue : 3  |  Page : 292-293  

An unusual case of prolonged intrapulmonary bullet impaction in a child and its successful extraction


1 Department of Pediatrics, Dubai Hospital, Dubai, UAE
2 Department of Cardiothoracic Surgery, Dubai Hospital, Dubai, UAE

Date of Submission12-Aug-2020
Date of Acceptance23-Aug-2020
Date of Web Publication30-Apr-2021

Correspondence Address:
Mohamed Ashraf Kandath
Department of Pediatrics, Dubai Hospital, Dubai
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_660_20

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How to cite this article:
Kandath MA, Pawar AA. An unusual case of prolonged intrapulmonary bullet impaction in a child and its successful extraction. Lung India 2021;38:292-3

How to cite this URL:
Kandath MA, Pawar AA. An unusual case of prolonged intrapulmonary bullet impaction in a child and its successful extraction. Lung India [serial online] 2021 [cited 2021 May 8];38:292-3. Available from: https://www.lungindia.com/text.asp?2021/38/3/292/315304



Sir,

Stray bullet injury to lung parenchyma in children occurs in war zones. It causes either a high-velocity or low-velocity injury to the lung parenchyma, and is often fatal.[1] Occasionally, bullets can get impacted in the lung parenchyma for years without causing symptoms. Although the impacted foreign bodies can be surgically extracted, it can lead to complications.

A 7-year-old Somali girl was brought by her parents for elective surgical removal of a bullet impacted in her right chest about 3 years back. She was playing outside the house in her home country when a stray bullet hit her, and the parents admitted her to the nearest hospital with bleeding from the left anterior chest. She received emergency treatment to control the bleeding. However, the bullet could not be removed as the hospital was not well equipped and the treating team felt that bullet removal was risky. Thereafter, she was completely asymptomatic for almost 3 years. A routine chest X-ray anteroposterior view showed a metallic oval opacity seen projecting over the left lower lung zone, simulating an artifact. X-ray lateral view [Figure 1] showed a bullet-shaped metallic opacity seen projecting over the left lower lung zone, just lateral to the left cardiac border, in the left lower lobe. As the parents had moved to Dubai, they brought her to our hospital for elective surgical removal of the bullet. Examination revealed a well-grown girl with normal systemic examination.
Figure 1: X-ray lateral view showing a bullet-shaped metallic opacity seen projecting over the left lower lung zone, just lateral to the left cardiac border, in the left lower lobe

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The parents were explained the asymptomatic nature of the problem and the possible complications following the removal of the impacted bullet in the lung. On the parents' request, the bullet [Figure 2] was successfully removed by video-assisted thoracoscopic (VATS)-assisted left thoracotomy.
Figure 2: Impacted bullet removed by video-assisted thoracoscopic-assisted left thoracotomy

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Postoperatively, she developed persistent left-sided pneumothorax. She underwent re-exploration, left thoracotomy for decortication, and wedge resection of the left lower lobe due to bronchopleural fistula 2 weeks after the initial procedure. She responded well to the procedure with good expansion of the left lung and was discharged home in good clinical condition.

On follow-up, she is doing well, quite active at school with no activity restriction.

There has been a marked increase in thoracic injuries due to firearm wounds in children in the last decade. Penetrating injuries account for 10%–20% of all pediatric trauma admissions at most centers.[2] Gunshot wounds are responsible for the overwhelming majority of penetrating traumatic injuries and have a significantly higher mortality rate than do blunt injury mechanisms. The severity of injury depends on the type of weapon used and the energy involved. High-velocity impact leads to contusion and tissue damage over a considerable area along the path of bullet.[3] Gunshot wounds often are deeper than stab wounds, resulting in perforating injury with an exit wound.[4] Gunshots have less predictable pattern of injury, which could be not only from the direct path of the bullet but can also be from shock waves caused by the bullet.

The management of penetrating injuries can be quite challenging and often requires rapid assessment and intervention. Specific management principles are guided by the anatomic location of injury, the determination of trajectory, and the suspected organs injured. Ballistic wounds can occur from a variety of flying objects such as bullets, which could be stray bullets, grenades, and flying glass.

Low-velocity injury is not usually deeper and follows an erratic path through soft tissues. Rarely, especially stray bullets can be retained in the body. Our case is a rare instance of retention of a stray bullet in the lung parenchyma. The bullet was almost encapsulated by the fibrous tissue and did not produce any symptoms for the last 3 years. The chest X-ray especially lateral view will usually demonstrate the bullet. Surgery can be avoided in very asymptomatic children as surgical interventions sometimes can lead to complications as in our child. Thus, one can resort to the wait-and-watch policy in very asymptomatic children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Leventhal JM, Gaither JR, Sege R. Hospitalizations due to firearm injuries in children and adolescents. Pediatrics 2014;133:219-25.  Back to cited text no. 1
    
2.
Cotton BA, Nance ML. Penetrating trauma in children. Semin Pediatr Surg 2004;13:87-97.  Back to cited text no. 2
    
3.
Eren S, Balci AE, Ulku R, Cakir O, Eren MN. Thoracic firearm injuries in children: Management and analysis of prognostic factors. Eur J Cardiothorac Surg 2003;23:888-93.  Back to cited text no. 3
    
4.
Creech O Jr., Pearce CW. Stab and gunshot wounds of the chest. Diagnosis and treatment. Am J Surg 1963;105:469-83.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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