Right Coronary Perforation Due to a Toothpick Ingested at a Barbecue
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《新英格兰医药杂志》
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 1A and Figure 1B), and its passage through the diaphragm was identified (Figure 1C).
Figure 1. Injury Due to Ingestion of a Toothpick.
Panel A shows the 3.5-cm wooden toothpick that was responsible for the coronary lesion. In Panel B, the arrow indicates the site of perforation of the right coronary artery. In Panel C, the needle identifies the passage of the foreign body through the diaphragm.
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
References
Li SF, Ender K. Toothpick injury mimicking renal colic: case report and systematic review. J Emerg Med 2002;23:35-38.
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.
Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984;252:796-797.
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.
Singh AC, Gurney M. Toothpick penetration of stomach. Gastrointest Endosc 2003;57:239-239.
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 1A and Figure 1B), and its passage through the diaphragm was identified (Figure 1C).
Figure 1. Injury Due to Ingestion of a Toothpick.
Panel A shows the 3.5-cm wooden toothpick that was responsible for the coronary lesion. In Panel B, the arrow indicates the site of perforation of the right coronary artery. In Panel C, the needle identifies the passage of the foreign body through the diaphragm.
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
References
Li SF, Ender K. Toothpick injury mimicking renal colic: case report and systematic review. J Emerg Med 2002;23:35-38.
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.
Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984;252:796-797.
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.
Singh AC, Gurney M. Toothpick penetration of stomach. Gastrointest Endosc 2003;57:239-239.