Journal of Indian Association of Pediatric Surgeons Medknow Publications on behalf of the Indian Association of Pediatric Surgeons ISSN: 0971-9261 EISSN: 1998-3891 Vol. 10, Num. 4, 2005, pp. 252-253

Journal of Indian Association of Pediatric Surgeons, Vol. 10, No. 4, October-December, 2005, pp. 252-253

Case Reports

Mauling by monkey: A rare cause of intestinal perforation in a neonate

Singh Narinder, Goswamy HL, Digra NC, Sharma R, Mahajan V

Division of Pediatric Surgery, Postgraduate Department of Surgery, Government Medical College Jammu, Jammu and Kashmir-180 016, India
Correspondence Address: Narinder Singh, House No. 28, Sector-9, Trikuta Nagar, Jammu, Jammu and Kashmir-180 012, India, Email: nsingh321@rediffmail.com

Code Number: ip05059

Abstract

Keywords: Neonatal bowel perforation, Penetrating trauma, Animal injury

In neonates, the common causes of bowel perforation, reported in the literature are; necrotizing enterocolitis, Hirschsprung′s disease, idiopathic bowel perforation, atresia of the gut and iatrogenic trauma[1] Although domestic animals like dogs, cows, donkey and rams have been reported to be the potential cause of serious intra-abdominal injuries in children,[2] however, a wild animal like monkey leading to traumatic bowel perforation in a neonate is unknown.[4]

Case report

A 25 day old female baby was admitted in our surgical unit with history of mauling by a wild monkey about 72- hrs back. When the baby was sleeping in a room all alone, mother of the baby heard a cry and saw a monkey on the bed of the baby.She rushed into the room and found wound marks over the abdomen of the baby,which were bleeding and applied some antiseptics over them. The baby was apparently alright upto 24 hrs after the injury when she started abdominal distention, bilious vomiting and fever. Since the patient hailed from a far off hilly area in Jammu province of J&K state, she was brought to the hospital only 3- days after the injury. On examination the patient was in early septicemia and abdominal wall had cellulites with multiple wound marks of injury [Figure - 1].

One of the wounds on the left side of umbilicus was bulging, when baby cried, thereby suggesting a possible communication with the peritoneal cavity. Abdomen was uniformly distended with guarding and tenderness. Plain x-rays and ultrasound of the abdomen showed pneumoperitoneum, free fluid in the peritoneal cavity and dilated bowel loops suggestive of hollow viscus perforation [Figure - 2]. Peripheral blood film and haemogram had features of early septicemia. Renal parameters and liver function tests including coagulogram were within normal limits. The patient was resuscitated with nasogastric aspiration, intravenous fluids and antibiotics (ceftriaxone, amikacin and metronidazole.)

After initial stabilization, exploratory laparotomy was performed through right supraumblical transverse incision. On opening the peritoneum, free air and bile stained fluid came out. Distended bowel loops with fibrinous adhesions[5] and flakes were noticed to the left side of umbilicus. After removing the flakes, a 5-mm hole was noticed in the parietal peritoneum which was communicating externally with one of the wounds on the anterior abdominal wall. After detailed and careful inspection of entire gut, a 2-mm size perforation was found in the distal ileum on antimesentric border [Figure - 3]. Single layer closure of the perforation with 4-0 vicryl, interrupted sutures was performed and a drain was left in the peritoneal cavity after toileting it with warm saline. The patient continued on nasogastric aspiration, intravenous fluids and antibiotics in the postoperative period. Feeding was resumed after 72- hrs of the operation and baby was discharged on tenth postoperative day.[6]

Discussion

Blunt or penetrating trauma accounts for the majority of gastrointestinal injuries in children.[3] Penetrating abdominal injury occurs in only 5% of the children who sustain trauma.[4] Common cause of penetrating abdominal trauma in children are gunshot wounds,[5] road traffic accidents, stabbing, fall on sharp objects, sport injuries[6] and domestic animals.[2] Among animals, in developed countries, dog bites are the commonest cause of such injuries. Whereas in developing countries others domestic animal like cows, horn gores, donkey and ram are the main culprits causing abdominal trauma which often result in intestinal contusions and evisceration.[2] Bowel injuries in neonates leading to perforation of gastrointestinal track that has been reported in the literature are mostly due to iatrogenic causes like; feeding tubes, rectal thermometers, catheters, enemas, intrauterine exchange transfusion and paracentesis of ascetic fluid.[1] Although any other etiology of the perforation in neonates is possible, however, after reviewing the available pertinent literature, we have not comes across any case report where neonatal bowel have been injured because of penetrating trauma by a wild monkey. The case seems to be unique because of rarity of such mode of injury in the neonatal age group.

References

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