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To the Editor: Retained grenade fragments may slowly migrate in the body over time and thus may not become symptomatic for many years. For instance, Wittich¹ reported a case of a grenade fragment that migrated from the leg 35 years after injury. Similarly, retained shrapnel may migrate several decades after the original injury and has been reported to cause late effects such as biliary obstruction,² bowel perforation,³ and brain abscess.⁴ These reports describe cases in which the fragment is embedded in a relatively large space within the body. Herein I report a case of fragment extrusion from the face 60 years after the original injury.

Report of a Case
In the fall of 2002, a 70-year-old man complained of an inflammatory nodule that had developed on the left side of his chin during the preceding few days (Figure 1, A). The nodule was firm, well circumscribed, erythematous, and slightly warm. Other areas of the facial skin were healthy, without acne, rosacea, or cysts. The patient reported that a similar nodule had developed over the left mandible 3 months earlier; the nodule had opened spontaneously, with expulsion of a small hard object. The patient was otherwise in good health. Upon excision, the nodule was found to contain a 4-mm metallic fragment (Figure 1, B).

View larger version (60K): [in this window] [in a new window] Figure. Inflammatory Nodule and Excised Metallic Fragment A, Arrow indicates inflammatory nodule on chin. B, 4-mm metallic fragment excised from chin nodule.

The patient recalled that as a boy in 1942 or 1943, he had found a hand grenade in his village in Italy. He stated that he had taken the pin out and the grenade detonated in front of him. Although he did have some injuries as a result of this, he stated that they had healed rapidly without medical intervention. The patient's relatives recalled that he did have some wounds on the left side of the face after this incident. The patient did not perform any other activities that would put him at risk for facial injury.

Comment
Exposure to hand grenades may be relatively common among civilians in war zones.⁵ The exact contents of hand grenades may differ, according to the type and destination: defensive or offensive, incendiary, suffocating, or smoke-producing. Defensive hand grenades, such as those used in World War II, generally cause serious injury only in the immediate vicinity of their shock wave. However, they produce hundreds or thousands of tiny missiles that typically weigh less than 200 mg and have diameters of 1 to 4 mm. Thus, they generally have a poor capacity for penetration due to their low mass and unfavorable aerodynamic characteristics.^6-7 The resulting wound channels are usually of small diameter with little bruising or tearing of tissue, and most missiles are absorbed by soft tissue.

This patient's symptom-free period of 60 years, as well as the relative absence of soft tissue in his face, are both unique features of this case. It is unclear whether the nearly simultaneous extrusion of these 2 foreign bodies 60 years after the injury was a coincidence or whether it was related to some underlying systemic or environmental factor. Explosive fragments are sometimes discovered as incidental findings during radiological examinations. This case underscores the fact that such fragments may pose a lifelong risk of migration and should be considered in the differential diagnosis of patients who were present in war zones.

Pierre-Dominique Ghislain, MD
Department of Dermatology
Université Catholique de Louvain
Bruxelles, Belgium

1. Wittich AC. Diagnosis and removal of a grenade fragment from the Vietnam war 35 years after injury. Mil Med. 2002;167:519-520. PUBMED 2. Mitchell R, Kerr R, Barton J, Schmidt A. Biliary obstruction secondary to shrapnel. Am J Gastroenterol. 1991;86:1531-1534. PUBMED 3. Symonds RP, Mackay C, Morley P. The late effect of grenade fragments. J R Army Med Corps. 1985;131:68-69. PUBMED 4. Lee JH, Kim DG. Brain abscess related to metal fragments 47 years after head injury: case report. J Neurosurg. 2000;93:477-479. ISI | PUBMED 5. Coupland RM. Hand grenade injuries among civilians. JAMA. 1993;270:624-626. FREE FULL TEXT 6. Karger B, Zweihoff RF, DuChesne A. Injuries from hand grenades in civilian settings. Int J Legal Med. 1999;112:372-375. PUBMED 7. Cooper GJ, Ryan JM. Interaction of penetrating missiles with tissues: some common misapprehensions and implications for wound management. Br J Surg. 1990;77:606-610. FULL TEXT | ISI | PUBMED

JAMA. 2003;290:1317-1318.

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