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A case of fatal coin battery ingestion in a 2-year-old child
Forensic Science International 198 (2010) e19–e22
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Case report
A case of fatal coin battery ingestion in a 2-year-old child V. Soerdjbalie-Maikoe a, R.R. van Rijn a,b,* a b
Department of Pathology and Toxicology, Netherlands Forensic Institute, The Hague, The Netherlands Department of Radiology, Academic Medical Centre/Emma Children’s Hospital Amsterdam, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 September 2009 Received in revised form 18 December 2009 Accepted 1 February 2010 Available online 23 February 2010
Foreign body aspiration is frequently encountered in young children, in the majority of cases it will not lead to an adverse outcome. However, in case of coin battery ingestion more serious adverse outcomes, including death, have been reported. We present a case with fatal outcome due to exsanguination, of a 2year-old child with an aberrant right subclavian artery (or arteria lusoria) and coin battery ingestion. Radiological and autopsy findings and relevant literature are discussed. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Coin battery Ingestion Fatal Radiology Child
1. Introduction Foreign body aspiration is frequently encountered in young children, in most cases it will not lead to an adverse outcome. Arana et al. analyzed 325 consecutive cases in a 15-year period [1]. In their study in 150 of cases (46%) natural elimination occurred and in all cases, the clinical outcome was uneventful. In case of battery ingestion complications are reported to be higher and these can be severe. There have been reports of severe complications such as oesophageal perforation, vocal cord paralysis, mediastinitis and even death due to exsanguination [2–10]. In this case report we present a case of coin battery ingestion with a fatal outcome. 2. Case report 2.1. Case history This is a case of a 2-year-old girl, with no medical history, presenting to a general practitioner with a clinical history of a sore throat, 40–41 8C fever, and coughing since 4 days. Conservative treatment was initiated. Six days later she was presented again with progressive symptoms of diarrhoea and vomiting after every drink or meal. She was referred to a paediatrician.
* Corresponding author at: Department of Radiology, Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam Zuid-Oost, The Netherlands. Tel.: +31 20 5669111; fax: +31 20 5669119. E-mail address: [email protected] (R.R. van Rijn). 0379-0738/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2010.02.001
Clinical examination showed a well-oriented child without signs of dehydration, but with reddened swollen tonsils and swollen nasal mucosa. The diagnosis upper airway infection was made and she was sent home with advice for optimal liquid intake and acetaminophen for relief of pain and fever. Five days later she developed convulsions, midazolam (administered by the ambulance personnel) relieved the convulsions and she was transported to a nearby hospital. A few hours after admission, she developed hypotension, anaemia, melaena, and haematemesis and collapsed. A chest radiograph was obtained. The chest radiograph showed the presence of a foreign body (Fig. 1). Because of her deteriorating clinical condition she was transferred to a university hospital. Upon arrival in the university hospital a contrast enhanced CTscan was performed on which the presence of the foreign body, located in the oesophagus, was confirmed and a haematothorax was diagnosed (Fig. 2). Extravasation of contrast, as a sign of active haemorrhage, in the oesophagus was observed. No specific localization of the haemorrhagic focus was reported. Based on these findings an emergency lateral thoracotomy was performed and besides the foreign body, a substantial amount of blood was removed from the thoracic cavity. The haemorrhagic focus was difficult to detect and she died shortly after the start of surgery. As there were doubts regarding medical intervention and probable negligence of involved medical professionals, a forensic autopsy was requested by the public prosecutors. 2.2. Autopsy findings At autopsy surgical incisions and anatomical changes due to the right lateral thoracotomy were noted. There was paleness of the
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V. Soerdjbalie-Maikoe, R.R. van Rijn / Forensic Science International 198 (2010) e19–e22
Fig. 1. Chest radiograph shows the foreign body projected over the mediastinum. The foreign body shows a ring like shadow, caused by the bevelled edge of the battery, which is characteristic for a coin battery (inset) [22].
face and lips, internal organs were pale and flabby, there was blood in the gastrointestinal tract (Fig. 3) and blood around the anal opening. These are all signs of severe blood loss. There were signs of focal mediastinitis, oesophageal perforation and oesophagitis (Fig. 4A–C).
Fig. 2. Maximum intensity projection (8 mm) of the chest shows the battery (open arrow), the arteria lusoria (arrow) and active contrast extravasation (arrowhead).
Fig. 4. (A) At autopsy the oesophagus showed a posterior perforation (arrow). Note the discoloration at the edge of the oesophageal perforation. (B) Crosssection of the oesophagus at the site of perforation shows discontinuation of epithelial lining, extravasation of erythrocytes and reactive changes characterised by fibroblastic reaction and inflammation (magnification 2.5). (C) Detail of (B) shows black discoloration, probably due to corrosion of the coin battery (magnification 20).
Fig. 3. A blood filled stomach was seen at autopsy.
An unexpected autopsy finding was the presence of a right aberrant subclavian artery, also called arteria lusoria (Fig. 5), which was perforated at the level where the coin battery was lodged in the oesophagus (on revision of the CT this vascular anomaly was clearly depicted–Fig. 6). This was the focus of the fatal haemorrhage. The cause of death was exsanguination due to an arteroesophageal fistula resulting from coin battery ingestion.
V. Soerdjbalie-Maikoe, R.R. van Rijn / Forensic Science International 198 (2010) e19–e22
e21
the battery showed corrosion, and as far as could be assessed using light microscopy there was no leakage from the battery. According to the manufacturers specification these lithium batteries should deliver 3.0 V and has an end-point-voltage of 2.0 V. At examination it however had a measured voltage of 1.09 V, it can thus be concluded that the battery is exhausted. 3. Discussion
Fig. 5. At autopsy the arteria lusoria showed an aortoesophageal fistula (arrow), from which the child had exsanguinated.
2.3. Coin battery The surgically removed foreign body, a coin battery (Mitsubishi type CR 2032 E, Mitsubishi Electric Corporation, Japan), was delivered together with the corpse for further investigation (Fig. 7). The diameter of the coin battery was 20 mm. At visual inspection
Fig. 6. 3D shaded surface rendering of the contrast extravasation from the arteria lusoria (arrowhead) and the coin battery (arrow). It illustrates their close relation. The arteria lusoria shows a characteristic oblique course, crossing the mediastinum from left inferior to right superior.
Fig. 7. Coin battery, showing signs of corrosion, removed during surgery.
Foreign body ingestion is a problem which, in paediatrics, is mainly seen in the young children, with a peak incidence between 6 months and 3 years [11,1,12]. Although every parent knows that young children can be virtual vacuum cleaners, no clear data on the epidemiology of foreign body ingestion is available. An anonymous home-based mail survey of parents in suburban Maryland showed that out of 1510 children 61 (4.0%, mean age 2.8 years) children had, according to their parents, swallowed a coin [13]. In all cases there was no need for intervention and none of the children experienced an adverse outcome. In a study by Litovitz and Schmitz data from the National Button Battery Ingestion Hotline and Registry, established in 1982 at Georgetown University (Washington, DC, USA) and functioning as an emergency consultation service and case registry, were analysed [14]. In a 7-year period 2382 cases of ingested batteries were reported to the registry, in 16 (0.67%) cases the battery became lodged in the oesophagus. In 10 cases (62.5%) there was no or minor effect, in 3 cases (18.8%) a moderate effect, in which case the patient exhibited signs or symptoms which were multiple, pronounced, prolonged, or systemic in nature but not life-threatening and not resulting in residual disability, and in 2 cases (12.5%) a major effect, in which case either a life-threatening situation occurred or developed permanent disability. No deaths due to battery ingestion were reported in this study. Yardeni et al. using Medline reviewed the literature from 1979 to 2002, combining ‘‘button battery’’ and ‘‘esophageal burn’’ as keywords [2]. Including 1 case of their own 20 cases were reviewed. There was an equal sex distribution and the majority of cases (65%) occurred in children under the age of 2 years. In 19 cases it was known how long the battery had been lodged in the oesophagus. In 12 children the diagnosis was delayed in 6 of them for more than 1 week and in 2 for longer than a month. This is in keeping with our case, where there was a significant delay in diagnosis. We could find four previously published cases of fatal exsanguination in literature; the first case was a 16-month-old girl who, within 1 day after removal of the coin battery, exsanguinated from an aortoesophageal fistula [5]. The second case was a 3-year-old girl who was admitted because of dysphagia due to a coin battery lodged in the oesophagus [10]. On the fifth day post-endoscopy she had massive haematemesis and could not be resuscitated. Although autopsy was not performed it seems most likely that she died as a result of an aortoesophageal fistula. The third case was a 19-month-old boy who on the eighth day after removal of an oesophageal located coin battery was presented with increasing lethargy and cyanosis and who rapidly deteriorated leading to emergency lateral thoracotomy which showed an oesophageal-aortic fistula [8]. Like in our case during the surgical procedure the boy, despite resuscitation, succumbed. The fourth case, published in a Danish journal, was a 14-month-old child who died from exsanguination due to an aorto-oesophageal fistula [9] In literature four mechanisms of injury due to battery ingestion have been suggested [2]: 1. Local toxic effect: this can be the case in mercuric oxide batteries. Some of these batteries can contain up to 5 g of mercuric oxide.
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V. Soerdjbalie-Maikoe, R.R. van Rijn / Forensic Science International 198 (2010) e19–e22
This is well above the lethal dose [15]. In our case the battery contained lithium which in itself can cause toxicity, however the reported lithium levels in battery ingestion are well below toxic levels [16]. 2. Electrical currents and resulting mucosal burns: based on animal experiments it has been shown that the mere presence of an electrical current is sufficient to cause local damage [17]. The oesophagus wraps around the battery and thus closes the circuit allowing for a current to run through the oesophagus. Langkau and Noesges performed an in vitro study showing that as a result from production of hydroxide by electrolysis the pH changed rapidly and significantly [18]. In 30 s the pH changed from 0 to 11 at the negative surface within 30 s. 3. Pressure necrosis: this is not only possible in case of a coin battery but with any foreign body and is the result from prolonged local pressure on tissue. 4. Caustic injury resulting from leakage from the coin battery. In this case it is not completely clear how long the coin battery had been lodged in the oesophagus, but if we assume that the first complaints were also related to the coin battery ingestion it had been in the oesophagus for at least 11 days. On examination the coin battery was shown to have no leakage and therefore caustic injury cannot have played a significant role. The voltage of the battery was measured to be 1.09 V (thus exhausted according to the manufacturers specifications), and at the time of examination most likely not sufficient to cause electrical currents and resulting mucosal burns, however it is not know if the battery was already low in voltage when swallowed or that it ran low inside the oesophagus. Given the prolonged period of time the coin battery had been in place pressure necrosis, and resulting mediastinitis, will have played a significant role in the process. From clinical use Lithium, which is a renally excreted alkali metal, known to be toxic [19]. Symptoms of lithium intoxication range from nausea and diarrhoea at low levels to coma, convulsion and cardiac arrhythmia at high levels. In clinical use the maintenance treatment therapeutic levels of bipolar disorders should be between 0.6 and 1.2 mequiv./L [20]. However, toxicity can occur at levels of 1.5 mequiv./L. One reported case of systemic lithium absorption as a result of coin battery ingestion could be found [16]. Aberrant right subclavian artery or arteria lusoria is one of the most common aortic arch abnormalities, occurring in nearly 1% of the population [21]. The arteria lusoria arises from the left side of the normal right-sided aortic arch and crosses the mediastinum, behind the oesophagus and trachea. In the majority of cases the patients obliquely, from left inferior to right superior have no symptoms however; complaints of chest pain, dysphagia, and dyspnoea have been described.
To our knowledge this is the first reported case of an arteroesophageal fistula between an arteria lusoria and the oesophagus, due to coin battery ingestion leading to a fatal exsanguination. References [1] A. Arana, B. Hauser, S. Hachimi-Idrissi, Y. Vandenplas, Management of ingested foreign bodies in childhood and review of the literature, Eur. J. Pediatr. 160 (2001) 468–472. [2] D. Yardeni, H. Yardeni, A.G. Coran, E.S. Golladay, Severe esophageal damage due to button battery ingestion: can it be prevented? Pediatr. Surg. Int. 20 (2004) 496– 501. [3] D.S. Blatnik, R.J. Toohill, R.H. Lehman, Fatal complication from an alkaline battery foreign body in the esophagus, Ann. Otol. Rhinol. Laryngol. 86 (1977) 611– 615. [4] N.B. Slamon, J.H. Hertzog, S.H. Penfil, R.C. Raphaely, C. Pizarro, C.D. Derby, An unusual case of button battery-induced traumatic tracheoesophageal fistula, Pediatr. Emerg. Care 24 (2008) 313–316. [5] C.L. Shabino, A.N. Feinberg, Esophageal perforation secondary to alkaline battery ingestion, JACEP 8 (1979) 360–363. [6] M. Alkan, I. Buyukyavuz, D. Dogru, E. Yalcin, I. Karnak, Tracheoesophageal fistula due to disc-battery ingestion, Eur. J. Pediatr. Surg. 14 (2004) 274–278. [7] K. Sinclair, I.D. Hill, Button Battery Ingestion, Wiley, J.F. Up-to-Date (5-5-2009) http://www.uptodate.com/online/content/topic.do?topicKey=ped_tox/4417& selectedTitle=14&source=search_result. [8] J.M. Hamilton, S.A. Schraff, D.M. Notrica, Severe injuries from coin cell battery ingestions: 2 case reports, J. Pediatr. Surg. 44 (2009) 644–647. [9] A. Mortensen, N.F. Hansen, O.M. Schiodt, Cardiac arrest in child caused by button battery in the oesophagus and complicated by aorto-oesophageal fistula, Ugeskr. Laeger. 171 (2009) 3098–3099. [10] D.L. Sigalet, J.M. Laberge, M. DiLorenzo, V. Adolph, L.T. Nguyen, S. Youssef, F.M. Guttman, Aortoesophageal fistula: congenital and acquired causes, J. Pediatr. Surg. 29 (1994) 1212–1214. [11] M.C. Uyemura, Foreign body ingestion in children, Am. Fam. Physician 72 (2005) 287–291. [12] W. Cheng, P.K. Tam, Foreign-body ingestion in children: experience with 1,265 cases, J. Pediatr. Surg. 34 (1999) 1472–1476. [13] G.P. Conners, J.M. Chamberlain, P.R. Weiner, Pediatric coin ingestion: a homebased survey, Am. J. Emerg. Med. 13 (1995) 638–640. [14] T. Litovitz, B.F. Schmitz, Ingestion of cylindrical and button batteries: an analysis of 2382 cases, Pediatrics 89 (1992) 747–757. [15] D.M. Temple, M.C. McNeese, Hazards of battery ingestion, Pediatrics 71 (1983) 100–103. [16] P.T. Mallon, J.S. White, R.L. Thompson, Systemic absorption of lithium following ingestion of a lithium button battery, Hum. Exp. Toxicol. 23 (2004) 193– 195. [17] M. Yamashlta, S. Saito, K. Koyama, H. Hattori, T. Ogata, Esophageal electrochemical burn by button-type alkaline batteries in dogs, Vet. Hum. Toxicol. 29 (1987) 226–230. [18] J.F. Langkau, R.A. Noesges, Esophageal burns from battery ingestion, Am. J. Emerg. Med. 3 (1985) 265. [19] M.P. Freeman, S.A. Freeman, Lithium: clinical considerations in internal medicine, Am. J. Med. 119 (2006) 478–481. [20] R.T. Timmer, J.M. Sands, Lithium intoxication, J. Am. Soc. Nephrol. 10 (1999) 666–674. [21] T. Berrocal, C. Madrid, S. Novo, J. Gutierrez, A. Arjonilla, N. Gomez-Leon, Congenital anomalies of the tracheobronchial tree, lung, and mediastinum: embryology, radiology, and pathology, Radiographics 24 (2004) e17. [22] M.D. Maves, T.V. Lloyd, J.S. Carithers, Radiographic identification of ingested disc batteries, Pediatr. Radiol. 16 (1986) 154–156.
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Case report
A case of fatal coin battery ingestion in a 2-year-old child V. Soerdjbalie-Maikoe a, R.R. van Rijn a,b,* a b
Department of Pathology and Toxicology, Netherlands Forensic Institute, The Hague, The Netherlands Department of Radiology, Academic Medical Centre/Emma Children’s Hospital Amsterdam, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 September 2009 Received in revised form 18 December 2009 Accepted 1 February 2010 Available online 23 February 2010
Foreign body aspiration is frequently encountered in young children, in the majority of cases it will not lead to an adverse outcome. However, in case of coin battery ingestion more serious adverse outcomes, including death, have been reported. We present a case with fatal outcome due to exsanguination, of a 2year-old child with an aberrant right subclavian artery (or arteria lusoria) and coin battery ingestion. Radiological and autopsy findings and relevant literature are discussed. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Coin battery Ingestion Fatal Radiology Child
1. Introduction Foreign body aspiration is frequently encountered in young children, in most cases it will not lead to an adverse outcome. Arana et al. analyzed 325 consecutive cases in a 15-year period [1]. In their study in 150 of cases (46%) natural elimination occurred and in all cases, the clinical outcome was uneventful. In case of battery ingestion complications are reported to be higher and these can be severe. There have been reports of severe complications such as oesophageal perforation, vocal cord paralysis, mediastinitis and even death due to exsanguination [2–10]. In this case report we present a case of coin battery ingestion with a fatal outcome. 2. Case report 2.1. Case history This is a case of a 2-year-old girl, with no medical history, presenting to a general practitioner with a clinical history of a sore throat, 40–41 8C fever, and coughing since 4 days. Conservative treatment was initiated. Six days later she was presented again with progressive symptoms of diarrhoea and vomiting after every drink or meal. She was referred to a paediatrician.
* Corresponding author at: Department of Radiology, Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam Zuid-Oost, The Netherlands. Tel.: +31 20 5669111; fax: +31 20 5669119. E-mail address: [email protected] (R.R. van Rijn). 0379-0738/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2010.02.001
Clinical examination showed a well-oriented child without signs of dehydration, but with reddened swollen tonsils and swollen nasal mucosa. The diagnosis upper airway infection was made and she was sent home with advice for optimal liquid intake and acetaminophen for relief of pain and fever. Five days later she developed convulsions, midazolam (administered by the ambulance personnel) relieved the convulsions and she was transported to a nearby hospital. A few hours after admission, she developed hypotension, anaemia, melaena, and haematemesis and collapsed. A chest radiograph was obtained. The chest radiograph showed the presence of a foreign body (Fig. 1). Because of her deteriorating clinical condition she was transferred to a university hospital. Upon arrival in the university hospital a contrast enhanced CTscan was performed on which the presence of the foreign body, located in the oesophagus, was confirmed and a haematothorax was diagnosed (Fig. 2). Extravasation of contrast, as a sign of active haemorrhage, in the oesophagus was observed. No specific localization of the haemorrhagic focus was reported. Based on these findings an emergency lateral thoracotomy was performed and besides the foreign body, a substantial amount of blood was removed from the thoracic cavity. The haemorrhagic focus was difficult to detect and she died shortly after the start of surgery. As there were doubts regarding medical intervention and probable negligence of involved medical professionals, a forensic autopsy was requested by the public prosecutors. 2.2. Autopsy findings At autopsy surgical incisions and anatomical changes due to the right lateral thoracotomy were noted. There was paleness of the
e20
V. Soerdjbalie-Maikoe, R.R. van Rijn / Forensic Science International 198 (2010) e19–e22
Fig. 1. Chest radiograph shows the foreign body projected over the mediastinum. The foreign body shows a ring like shadow, caused by the bevelled edge of the battery, which is characteristic for a coin battery (inset) [22].
face and lips, internal organs were pale and flabby, there was blood in the gastrointestinal tract (Fig. 3) and blood around the anal opening. These are all signs of severe blood loss. There were signs of focal mediastinitis, oesophageal perforation and oesophagitis (Fig. 4A–C).
Fig. 2. Maximum intensity projection (8 mm) of the chest shows the battery (open arrow), the arteria lusoria (arrow) and active contrast extravasation (arrowhead).
Fig. 4. (A) At autopsy the oesophagus showed a posterior perforation (arrow). Note the discoloration at the edge of the oesophageal perforation. (B) Crosssection of the oesophagus at the site of perforation shows discontinuation of epithelial lining, extravasation of erythrocytes and reactive changes characterised by fibroblastic reaction and inflammation (magnification 2.5). (C) Detail of (B) shows black discoloration, probably due to corrosion of the coin battery (magnification 20).
Fig. 3. A blood filled stomach was seen at autopsy.
An unexpected autopsy finding was the presence of a right aberrant subclavian artery, also called arteria lusoria (Fig. 5), which was perforated at the level where the coin battery was lodged in the oesophagus (on revision of the CT this vascular anomaly was clearly depicted–Fig. 6). This was the focus of the fatal haemorrhage. The cause of death was exsanguination due to an arteroesophageal fistula resulting from coin battery ingestion.
V. Soerdjbalie-Maikoe, R.R. van Rijn / Forensic Science International 198 (2010) e19–e22
e21
the battery showed corrosion, and as far as could be assessed using light microscopy there was no leakage from the battery. According to the manufacturers specification these lithium batteries should deliver 3.0 V and has an end-point-voltage of 2.0 V. At examination it however had a measured voltage of 1.09 V, it can thus be concluded that the battery is exhausted. 3. Discussion
Fig. 5. At autopsy the arteria lusoria showed an aortoesophageal fistula (arrow), from which the child had exsanguinated.
2.3. Coin battery The surgically removed foreign body, a coin battery (Mitsubishi type CR 2032 E, Mitsubishi Electric Corporation, Japan), was delivered together with the corpse for further investigation (Fig. 7). The diameter of the coin battery was 20 mm. At visual inspection
Fig. 6. 3D shaded surface rendering of the contrast extravasation from the arteria lusoria (arrowhead) and the coin battery (arrow). It illustrates their close relation. The arteria lusoria shows a characteristic oblique course, crossing the mediastinum from left inferior to right superior.
Fig. 7. Coin battery, showing signs of corrosion, removed during surgery.
Foreign body ingestion is a problem which, in paediatrics, is mainly seen in the young children, with a peak incidence between 6 months and 3 years [11,1,12]. Although every parent knows that young children can be virtual vacuum cleaners, no clear data on the epidemiology of foreign body ingestion is available. An anonymous home-based mail survey of parents in suburban Maryland showed that out of 1510 children 61 (4.0%, mean age 2.8 years) children had, according to their parents, swallowed a coin [13]. In all cases there was no need for intervention and none of the children experienced an adverse outcome. In a study by Litovitz and Schmitz data from the National Button Battery Ingestion Hotline and Registry, established in 1982 at Georgetown University (Washington, DC, USA) and functioning as an emergency consultation service and case registry, were analysed [14]. In a 7-year period 2382 cases of ingested batteries were reported to the registry, in 16 (0.67%) cases the battery became lodged in the oesophagus. In 10 cases (62.5%) there was no or minor effect, in 3 cases (18.8%) a moderate effect, in which case the patient exhibited signs or symptoms which were multiple, pronounced, prolonged, or systemic in nature but not life-threatening and not resulting in residual disability, and in 2 cases (12.5%) a major effect, in which case either a life-threatening situation occurred or developed permanent disability. No deaths due to battery ingestion were reported in this study. Yardeni et al. using Medline reviewed the literature from 1979 to 2002, combining ‘‘button battery’’ and ‘‘esophageal burn’’ as keywords [2]. Including 1 case of their own 20 cases were reviewed. There was an equal sex distribution and the majority of cases (65%) occurred in children under the age of 2 years. In 19 cases it was known how long the battery had been lodged in the oesophagus. In 12 children the diagnosis was delayed in 6 of them for more than 1 week and in 2 for longer than a month. This is in keeping with our case, where there was a significant delay in diagnosis. We could find four previously published cases of fatal exsanguination in literature; the first case was a 16-month-old girl who, within 1 day after removal of the coin battery, exsanguinated from an aortoesophageal fistula [5]. The second case was a 3-year-old girl who was admitted because of dysphagia due to a coin battery lodged in the oesophagus [10]. On the fifth day post-endoscopy she had massive haematemesis and could not be resuscitated. Although autopsy was not performed it seems most likely that she died as a result of an aortoesophageal fistula. The third case was a 19-month-old boy who on the eighth day after removal of an oesophageal located coin battery was presented with increasing lethargy and cyanosis and who rapidly deteriorated leading to emergency lateral thoracotomy which showed an oesophageal-aortic fistula [8]. Like in our case during the surgical procedure the boy, despite resuscitation, succumbed. The fourth case, published in a Danish journal, was a 14-month-old child who died from exsanguination due to an aorto-oesophageal fistula [9] In literature four mechanisms of injury due to battery ingestion have been suggested [2]: 1. Local toxic effect: this can be the case in mercuric oxide batteries. Some of these batteries can contain up to 5 g of mercuric oxide.
e22
V. Soerdjbalie-Maikoe, R.R. van Rijn / Forensic Science International 198 (2010) e19–e22
This is well above the lethal dose [15]. In our case the battery contained lithium which in itself can cause toxicity, however the reported lithium levels in battery ingestion are well below toxic levels [16]. 2. Electrical currents and resulting mucosal burns: based on animal experiments it has been shown that the mere presence of an electrical current is sufficient to cause local damage [17]. The oesophagus wraps around the battery and thus closes the circuit allowing for a current to run through the oesophagus. Langkau and Noesges performed an in vitro study showing that as a result from production of hydroxide by electrolysis the pH changed rapidly and significantly [18]. In 30 s the pH changed from 0 to 11 at the negative surface within 30 s. 3. Pressure necrosis: this is not only possible in case of a coin battery but with any foreign body and is the result from prolonged local pressure on tissue. 4. Caustic injury resulting from leakage from the coin battery. In this case it is not completely clear how long the coin battery had been lodged in the oesophagus, but if we assume that the first complaints were also related to the coin battery ingestion it had been in the oesophagus for at least 11 days. On examination the coin battery was shown to have no leakage and therefore caustic injury cannot have played a significant role. The voltage of the battery was measured to be 1.09 V (thus exhausted according to the manufacturers specifications), and at the time of examination most likely not sufficient to cause electrical currents and resulting mucosal burns, however it is not know if the battery was already low in voltage when swallowed or that it ran low inside the oesophagus. Given the prolonged period of time the coin battery had been in place pressure necrosis, and resulting mediastinitis, will have played a significant role in the process. From clinical use Lithium, which is a renally excreted alkali metal, known to be toxic [19]. Symptoms of lithium intoxication range from nausea and diarrhoea at low levels to coma, convulsion and cardiac arrhythmia at high levels. In clinical use the maintenance treatment therapeutic levels of bipolar disorders should be between 0.6 and 1.2 mequiv./L [20]. However, toxicity can occur at levels of 1.5 mequiv./L. One reported case of systemic lithium absorption as a result of coin battery ingestion could be found [16]. Aberrant right subclavian artery or arteria lusoria is one of the most common aortic arch abnormalities, occurring in nearly 1% of the population [21]. The arteria lusoria arises from the left side of the normal right-sided aortic arch and crosses the mediastinum, behind the oesophagus and trachea. In the majority of cases the patients obliquely, from left inferior to right superior have no symptoms however; complaints of chest pain, dysphagia, and dyspnoea have been described.
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