Correspondence

A Delayed Complication after Injury in World War II

N Engl J Med 2006; 354:1963-1964May 4, 2006

Article

To the Editor:

In December 2004, an 84-year-old man presented with a painless supraclavicular mass on the right side. The mass had first been noted one year before and had gradually increased in size.

Sixty-one years earlier, in 1943 during World War II, in Russia, he had been wounded in the right shoulder and neck by grenade splinters. Most of the splinters were surgically removed. The postoperative period was uneventful. After the war he worked as a farmer.

Physical examination revealed a soft subcutaneous mass in the right supraclavicular region, measuring approximately 10 cm in diameter. The overlying skin was hyperemic, with three large bleeding ulcers (Figure 1Figure 1A Subcutaneous Mass in the Right Supraclavicular Region.). The white-cell count was 10,400 per cubic millimeter without a shift to the left, and the results of routine laboratory tests were within normal limits.

A chest radiograph showed metallic foreign bodies within the mass (Figure 2Figure 2A Chest Radiograph Showing Metallic Foreign Bodies (Arrows) within the Mass.). On computed tomography, the mass was homogeneous, 12.0 by 9.0 cm in size, with a central fistula. There was no evidence of lung metastasis, infiltration of the thoracic wall, or chest lymphoma. A biopsy specimen of the mass showed nonspecific sclerotic tissue and blood. Since the diagnosis remained unclear and a malignant tumor could not be ruled out, the mass was resected. Histopathological examination showed granulation tissue, a fibrin mass, and blood, with no sign of malignant disease but with metal fragments within the mass. After an uneventful postoperative course, the patient was discharged in stable condition.

The grenade splinters were steel, and there was no evidence of injury from a lead bullet. The patient died in November 2005.

A pseudotumoral, foreign-body–induced tissue reaction is an unusual complication of retained surgical material or instruments.1,2 It has been described after gunshot injury.3 Retained bullet fragments or grenade splinters in veterans of World War II are not uncommon. However, this large foreign-body–induced pseudotumor first presented more than 60 years after the injury occurred.

Alexey Surov, M.D.
Christiane Taege, M.D.
Curd Behrmann, M.D.
Martin Luther University, 06097 Halle, Germany
alex.surow@medizin.uni-halle.de

3 References

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   Serra J, Matias-Guiu X, Calabuig R, Garcia P, Sancho FJ, La Calle JP. Surgical gauze pseudotumor. Am J Surg 1988;155:235-237
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   Oey IF, Jeyapalan K, Entwisle JJ, Waller D. Pseudotumors of the lung after lung volume reduction surgery. Ann Thorac Surg 2004;77:1094-1096
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   Wakabayashi M, Reid JD, Bhattacharjee M. Foreign body granuloma caused by prior gunshot wound mimicking malignant breast mass. AJR Am J Roentgenol 1999;173:321-322
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Citing Articles (4)

Citing Articles

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   J. Neila, M. Perea, J.J. Ríos-Martín, F.M. Camacho. (2011) Reacción retardada a cuerpo extraño por alambre de acero inoxidable simulando un carcinoma basocelular. Actas Dermo-Sifiliográficas 102:9, 740-742
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   J. Neila, M. Perea, J.J. Ríos-Martín, F.M. Camacho. (2011) Delayed Foreign Body Reaction to Steel Wire Suture Resembling Basal Cell Carcinoma. Actas Dermo-Sifiliográficas (English Edition) 102:9, 740-742
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   Alexey Surov, Florian Thermann, Curd Behrmann, Rolf-Peter Spielmann, Malte Kornhuber. (2011) Late sequelae of retained foreign bodies after world war II missile injuries. Injury
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4. 4

   KURT L. MAGGIO, VICTOR F. KALASINSKY, MICHAEL R. LEWIN-SMITH, FLORABEL G. MULLICK. (2008) Wound Fragments from Cutaneous Sites of U.S. Military Personnel Deployed in Operation Iraqi Freedom: Clinical Aspects and Pathologic Characterizations. Dermatologic Surgery 34:4, 475-482
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