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We report an unusual case of self inflicted pneumothorax caused by self flagellation with a chain laden with knives during a religious Muslim festival. Despite many cases of pneumothorax having been described in the literature,1 we have been unable to find any of this nature.
A 27 year old Pakistani Muslim man was brought to our department by ambulance after complaining of pain in the right side of his chest. He belonged to the Shi‘ite branch of the Islamic faith and had been practising religious self flagellation on the same afternoon.
He reported the symptoms to have started three hours after the religious practice of self flagellation. The patient had flayed himself on the back with a chain laden with small curved knives.
On examination he was distressed and mild dyspnoeic. His pulse rate was 83 and blood pressure was 138/81. He maintained his oxygen saturations at 96% on air all throughout.
Examination of the chest revealed multiple scars from previous wounds and two new deep wounds to the skin on the right side of the posterior chest wall. There was also a large haematoma under the wound.
On auscultation there was decreased air entry on the right side of the chest.
A chest radiograph (fig 1) shows the presence of a large right sided pneumothorax.
A chest drain was inserted in the accident and emergency department and the patient was admitted to the hospital under the care of the thoracic surgeons.
Initial blood investigations revealed a raised white cell count of 20.1 with a neutrophilia of 17.0.
He made an uneventful recovery and the chest drain was removed the following day. He was discharged two days later.
The practice of self flagellation is common among the adherents of the Shi‘ite group of Islam on important religious occasions, particularly on the 10th day of the Islamic month of Moharram.2 This day commemorates the martyrdom of Imam Hussain, the grandson of the Prophet Mohammed, at the Battle of Kerbala, which took place in 680 AD.3 On this day large processions are carried out, by the Shi‘ite communities throughout the world. During the processions scenes from the battle of Kerbala are re-enacted and self flagellation is carried out. Such processions are becoming increasingly common in cities of the United Kingdom with large Muslim, particularly Pakistani communities.
The practice of self flagellation usually entails the participant flaying themselves on the upper back with chains and multiple short, blunt and either curved or straight knives attached to chains (fig 2). In our department we have frequently seen patients with multiple superficial lacerations to many areas of the body after self flagellation but we can find no report in the literature of a pneumothorax caused by self flagellation. Surprisingly, though the patient developed a large pneumothorax, he was clinically stable all throughout.
Ahmed Akhtar was involved in the management of the patient, thought and discussed the case, collected the pictures, and wrote the paper. Chanchal Bhattacharjee has discussed ideas and designs of this paper, participated in writing and editing the case report. Saima Khan has analysed the case and discussed the ideas and carried out the literature search. Peter Bradley and Anthony Shenton were actively involved in the primary management of the patient, provided the idea and discussed the core idea of the case report. Ahmed Akhtar and Chanchal Bhattacharjee will act as guarantors of the paper.