A young man nearly lost his life to a toothpick he didn’t even know he had swallowed, according to a harrowing report published Wednesday in The New England Journal of Medicine.
The three-inch wood pick, from a sandwich, traveled through most of his digestive tract without doing any harm. But then it poked through the intestinal wall and pierced an artery, creating a conduit for bacteria to invade his bloodstream and damaging the artery enough to cause serious bleeding.
For nearly three weeks, his symptoms — abdominal pain, fever, distressing gut trouble — mystified doctors. By the time they figured out what was wrong, he had a potentially fatal infection. It took extensive surgery to save him.
Injuries like this are not common, but cases have been reported in medical journals over the years.
Toothpicks are everywhere, jabbed into sliders, wraps, club sandwiches and cocktail garnishes. Often, people have no idea they swallowed one, maybe because they were distracted or eating in a hurry.
The picks — unscathed by stomach acid or digestive enzymes — have been found in the stomach and both small and large intestines. In a few cases they have worked their way into other organs, including the liver, pancreas, lung, kidney and even a coronary artery. They can be difficult or impossible to see on scans.
An analysis of 136 cases that were serious enough to be reported in medical journals found that nearly 10 percent were fatal.
For the young man in the new report, the first hint of trouble was a fever and pain in the right lower part of his abdomen, then nausea and diarrhea. He was 18, a professional athlete on the road with his team for training. His identity is being kept confidential by his doctors.
He went to an emergency room, where blood tests and a CT scan were normal. Doctors were stumped. After keeping him five hours for observation, they sent him back to his hotel, with no diagnosis.
Over the next two weeks, the pain lessened and he felt better, except for mild nausea. But then, on a trip to a different city, the pain returned. His bowel movements contained blood, and his temperature shot up to more than 103 degrees Fahrenheit. Again, he sought help at an emergency room.
This time, doctors ordered an M.R.I. scan in addition to the usual array of blood tests. But they still could not determine what was wrong. They gave him intravenous fluids and medicine for the fever. At the urging of his team’s internist, he headed back home to New England.
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Two days later, he saw the team doctor at the Massachusetts General Hospital in Boston. He was still sick and in pain. The internist ordered a colonoscopy for the next day, to examine the inside of his intestines.
Next morning, the young man called the team doctor and said he was sicker — feverish, passing more blood, and with worsening pain. The doctor told him to head to the Massachusetts General emergency room.
There, doctors found that he was lightheaded and feeling ill. They drew blood for cultures to look for infection, ran other tests for viral and bacterial illnesses and ordered a CT scan.
The cultures found bacteria in his bloodstream, but doctors could not see anything abnormal on the scan. He continued to worsen, with a racing pulse, a fever of 104 degrees, mental confusion and rapid breathing — signs of sepsis, a deadly response to an infection.
After receiving antibiotics, intravenous fluids and medicine for fever, he seemed to improve. But the next day, his temperature shot up to 105 degrees.
Doctors performed a colonoscopy. They still did not know what they were looking for, and suspected an unusual inflammatory disease, said Dr. Fabian J. Scheid, part of the medical team.
So they were stunned to find the toothpick, Dr. Scheid said. The doctors had not seen it on the scans. And the patient hadn’t remembered any odd sensations while eating, when doctors had taken his history.
As soon as the doctors removed the toothpick, blood began to spurt from the artery. It was life-threatening, and they could not stop it. Several operations would be needed to save the young man’s life.
They rushed him into another operating room, to repair the intestine and the artery. The toothpick had done so much damage that they had to cut out a 1.2 inch segment of the artery.
Then, to replace that segment, they had to remove a vein from the patient’s thigh and splice it into the artery.
Finally, because swelling from the procedures could cut off the circulation to his leg, surgeons made a series of large incisions in his calf to relieve pressure by opening the fascia, a sheet of connective tissue that wraps tightly around muscle.
The young man, who had gone into the colonoscopy expecting a minor procedure that would take an hour or two, instead woke up days later in intensive care, having had several major operations.
“It was a big adjustment,” Dr. Scheid said. “His big concern was his ability to do sports.”
Once the doctors told him about the toothpick, he thought back and did remember that shortly before becoming ill, he had eaten a sandwich that did not go down so well.
Young and strong, he was well enough to leave the hospital a week after surgery, walking without help. Regaining his status as an elite athlete required months of physical therapy. But he made a comeback: Seven months after his illness, he played in his first professional game.
Dr. Scheid emphasized that accidents like this one are pretty rare.
“It’s important to put these things in perspective,” he said.
Still, he’s not a fan of toothpicks.
“I stay away from them,” Dr. Scheid said. “I don’t offer them to any guests at my barbecue parties.”