Correspondence

Right Coronary Perforation Due to a Toothpick Ingested at a Barbecue

N Engl J Med 2005; 352:2249-2250May 26, 2005

Article

To the Editor:

Ingested toothpicks have often been reported as the cause of gastrointestinal injuries,1 and in one case a toothpick migrated into the pericardium, resulting in constrictive pericarditis.2 We report an unusual case of cardiac tamponade due to an ingested toothpick.

A 67-year-old woman with no pertinent medical history presented to the emergency department with chest pain and signs of cardiac tamponade (muffled heart sounds, low blood pressure, and vasoconstriction). The electrocardiogram showed Q waves in leads II, III, and aVF. The creatine kinase concentration was 736 U per liter (normal reference range, 20 to 160 U per liter), the level of MB isoform 94.7 ng per milliliter (normal reference range, 0.5 to 3.6 ng per milliliter), and the level of troponin I 25.6 ng per milliliter (normal reference range, 0.00 to 0.10 ng per milliliter). Transthoracic echocardiography showed massive pericardial effusion with early diastolic collapse of the right ventricle.

Because of the patient's hemodynamic deterioration, a drainage tube was introduced into the pericardial space as an emergency measure, returning 150 ml of bloody effusion. The patient was promptly taken to the operating room, where she underwent transesophageal echocardiography, which showed no evidence of aortic dissection. A diagnosis of postinfarction rupture of the ventricular free wall was suspected on the basis of clinical, laboratory, and imaging findings.

A median sternotomy was performed, and the pericardium was opened. After the evacuation of 600 ml of clotted blood, a bleeding site was identified in the right coronary artery, with bleeding due to perforation of the artery just before its bifurcation. Furthermore, when the diaphragmatic side of the heart was pulled up, a wooden toothpick, 3.5 cm long, was found (Figure 1AFigure 1Injury Due to Ingestion of a Toothpick. and Figure 1B), and its passage through the diaphragm was identified (Figure 1C).

After ligation of the right coronary artery, bypass grafting with a saphenous vein was performed. A laparotomy was carried out after closure of the chest; neither inflammation nor intestinal content was found in the peritoneum. In addition, we did not find the passageway of the foreign body through the gastric wall.

The postoperative course was uneventful. The patient was discharged after six days, and she returned to work after two months. The patient remembered having eaten meat rolls secured with toothpicks at a barbecue the night before her chest pain began.

One four-year survey3 found 8176 reported toothpick-related injuries in the United States, for a rate of 3.6 per 100,000 person-years. Five percent of these injuries involved internal organs.4,5 In the case of our patient, the toothpick migrated into the pericardium, presumably through the gastric wall, and the onset of symptoms mimicked postinfarction rupture of the free wall of the left ventricle. This unusual case emphasizes the uncommon but serious hazards associated with the ingestion of toothpicks.

Sandro Gelsomino, M.D.
Stefano Romagnoli, M.D.
Pierliugi Stefàno, M.D.
Careggi Hospital, 50139 Florence, Italy
sandrogelsomino@virgilio.it

5 References

1. 1

   Li SF, Ender K. Toothpick injury mimicking renal colic: case report and systematic review. J Emerg Med 2002;23:35-38
   CrossRef | Web of Science | Medline

2. 2

   Meyns BP, Faveere BC, Van de Werf FJ, Dotremont G, Daenen WJ. Constrictive pericarditis due to ingestion of a toothpick. Ann Thorac Surg 1994;57:489-490
   CrossRef | Web of Science | Medline

3. 3

   Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984;252:796-797
   CrossRef | Web of Science | Medline

4. 4

   Wichmann MW, Huttl TP, Billing A, Jauch KW. Laparoscopic management of a small bowel perforation caused by a toothpick. Surg Endosc 2004;18:717-718
   CrossRef | Web of Science | Medline

5. 5

   Singh AC, Gurney M. Toothpick penetration of stomach. Gastrointest Endosc 2003;57:239-239
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Yu-Jang Su, Yen-Chun Lai, Chang-Chih Chen, Chin Tang. (2009) Intra-abdominal abscess caused by toothpick injury. International Journal of Infectious Diseases 13:5, e264-e266
   CrossRef

2. 2

   Giuseppe R. Nigri, Emilio Di Giulio, Raffaella Di Nardo, Francesca Pezzoli, Francesco D’Angelo, Paolo Aurello, Matteo Ravaioli, Giovanni Ramacciato. (2008) Duodenal Perforation and Right Hydronephrosis Due to Toothpick Ingestion. The Journal of Emergency Medicine 34:1, 55-57
   CrossRef