An atypical cause of ST elevation

A 26-year-old previously healthy male presented with a history of sharp, sub-sternal chest pain. His initial electrocardiogram demonstrated ST elevation in the infero-lateral leads (Panel A). Coronary angiography demonstrated normal coronary arteries. Further investigation demonstrated a metallic body (Panel B, trans-thoracic echocardiogram, arrow and see Supplementary data online, Movie S2) in the left ventricle correlating with the current of injury on electrocardiogram. This was also seen on computed tomography (CT) (see Supplementary data online, Movie S1 and Panel C, sagittal CT, arrow) in addition to a pericardial effusion (Panel C, star). An echocardiogram with bubble study was negative for patent foramen ovale. The patient later admitted to breaking off a hypodermic needle he had been using to inject drugs into his arm. The needle likely migrated to the right atrium and then the right ventricle via normal venous return. We postulate that it went through the right ventricular free wall and then migrated in the pericardial space to the position seen in the images. (Panel A) Initial electrocardiogram demonstrating ST elevation in the infero-lateral leads. (Panel B) Trans-thoracic echocardiogram. Arrow indicates linear body in the left ventricle. (Panel C) Sagittal CT. Arrow and star indicates linear body in the left ventricle and pericardial effusion, respectively. Supplementary data are available at European Heart Journal – Cardiovascular Imaging online.