Hong Kong Journal of Emergency Medicine
Incidental radiological finding of charm needles
S Pothiawala
The charm needles, or susuks, are small, needle-shaped metallic talismans inserted subcutaneously in different parts of the body. This is a traditional practice, occasionally encountered in the Southeast Asian region. This case report describes two patients who were evaluated in the emergency department and incidentally found to have charm needles on the plain radiographs. These needles are not visible externally and have not been reported to cause any adverse effects. Emergency physicians should be aware of the existence of this traditional practice and chances of its incidental detection on radiographs. This would help avoid misdiagnosis and further investigations. It would also avoid susuks being considered as foreign bodies responsible for the patient's symptoms. (Hong Kong j.emerg.med. 2012;19:141-143) susuks X X
susuks
Keywords: Asia South Eastern, foreign body, traditional medicine
Introduction
Case 1
Charm needles, or susuks, are needle-shaped metallic talismans inserted subcutaneously in different parts of the body. This practice, still occasionally occurring in Southeast Asia, is seen most commonly in Malays, but has also been reported among Chinese and Indians.1 They are inserted in the body as talismans and are believed to improve the health and beauty of the wearer, cure aches and pains, protect the wearer from harm, achieve success in business and career, or improve relationship by casting a spell.2
A 24-year-old Malay Muslim woman presented to the emergency department (ED) with complaints of low back pain while moving furniture in her house. She was noted to have mechanical back pain with no spinal tenderness or neurological deficit. Plain radiograph of the lumbar spine was reported showing a linear radiopacity in the pelvis (Figure 1). There were no body piercings or any needles visible externally.
Case 2 Correspondence to: Sohil Pothiawala, MRCSEd(A&E), MMed(EM) Singapore General Hospital, Department of Emergency Medicine, Outram Road, Singapore 169608 Email:
[email protected]
A 55-year old Chinese man initially presented to the polyclinic for left loin pain suggestive of renal colic. The plain radiograph was reported as having a metallic density in the left flank (Figure 2). Hence the patient was referred to the ED. There was no past history of
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any surgery, trauma or acupuncture therapy or any history of undergoing traditional practice of needle insertion. Comparison with the intravenous urogram study done in 2006 showed the stable linear density at the same site.
Discussion Charm needles are inserted mainly in the cranio-facial region, and less often in other areas of the body like the chest, abdomen, breasts, limbs, mons pubis and spine. 1,3,4 They are inserted in the soft tissues of the body by "bomoh", or traditional healers who practice herbal medicine, using methods which are traditionally passed down over generations. These needles, 5-10 mm
Hong Kong j. emerg. med. Vol. 19(2) Mar 2012
in length and about 0.5 mm in diameter, are inserted by gentle rubbing in a way that is painless and leaves no external puncture marks.5 They are mostly made of gold, followed by silver and often mixed with copper. The analysis of the chemical composition found an average gold content of 89.75% and copper content of 10.25%.6 Gold is preferably used as it is biocompatible with tissues and noncorrosive while copper is used to increase its hardness and malleability.3 A study by Nambiar et al concluded that charm needles showed no ferromagnetic characteristics and it was safe for those patients to undergo MRI.1 The needles are not visible externally, nor felt on palpation. The number of needles inserted varies, with reported numbers ranging from 1 to 47 per patient,7 up to 80 needles in the face of a single patient.4 They usually remain intact for many years and do not cause any pain to the wearer.8 Their presence is usually kept a secret by the wearer for religious reasons or to ensure effectiveness of the talisman. Moreover, the wearer
Figure 1. Plain radiograph showing a charm needle in the
Figure 2. Plain radiograph showing a charm needle in the left
pelvis marked by arrow.
abdominal area marked by arrow.
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might be unaware of its existence inside the body as the needles could have been inserted at a young age. Some believe that the needles need to be removed before death or the wearer will be subjected to suffering before dying. Others believe that the presence of the needles at the time of death may lead to a painful death.3 Although rare, with increasing use of radiography, identification of these needles is reported. It can be clinically confused with foreign bodies and as the cause of patient's symptoms. Based on the site of the needles, they can be thought of as introduced during trauma, broken acupuncture needles, or as root fillings or (A) (B) restorative pins on dental radiographs.5 Charm needles have not been noted to cause any symptoms or adverse effects. They should be left alone, unless they lead to infection or complications. There has been a report of an embolised injection needle fragment to the heart in an intravenous drug abuser which was initially thought to be a subcutaneous charm needle by the reporting radiologist.9 Hence, they can lead to misdiagnosis, if not considered.
Conclusion Considering the increase in trans-continental travel and migration of people from the Southeast Asian region, emergency physicians worldwide should be aware of
the existence of the traditional practice of charm needle insertion and chances of its incidental detection on radiographs. This would help avoid misdiagnosis and further investigations. It would also avoid susuks being considered as foreign bodies responsible for the patient's symptoms.
References 1. N a m b i a r P, I b r a h i m N , Ta n d j u n g Y R M , Shanmuhasuntharam P. Susuk (charm needles) in the craniofacial region. Oral Radiol 2008;24(1):10-5. 2. Teo SK. A woman with hidden charm needles. J R Coll Physicians Edinb 2006;36(3):211-2. 3. Pande S. Incidental findings of Susuk in orthopaedic patients. Brunei Int Med J 2011;7(3):177-80. 4. Nor MM, Yushar A, Razali M, Rahman RA, Ramli R. Incidental radiological findings of susuk in the orofacial region. Dentomaxillofac Radiol 2006;35(6):473-4. 5. Shanmuhasuntharam P, Ghani SH. Susuks: charm needles in facial soft tissues. Br Dent J 1991;170(8): 309-11. 6. Loh FC, Ling SY. Analysis of the metallic composition of orofacial talismans. Oral Surg Oral Med Oral Pathol 1992;73(3):281-3. 7. Oon CL. Correspondence: "Charm needles". Med J Malaysia 1973;27(3):231-2. 8. Lim EC, Ng TH, Seet RC. A woman whose radiographs showed subcutaneous metallic objects. CMAJ 2005;173 (2):150-1. 9. Teo LL, Seto KY, Chai P, Venkatesh SK. Embolised injection needle fragment to the heart, mimicking a subcutaneous charm needle. Ann Acad Med Singapore 2010;39(6):499-500.
