And what about the lungs? A number of things could explain the problems in his lungs—including infections from soil bacteria he might encounter in his construction work or a parasitic infection found in Central America. But the cause that best fit was common pneumonia and, more specifically, based on the distribution of opacities in his lung, pneumonia caused by aspiration (inhaling food particles or other things that are not air)—which is something that can happen when people drink excessive amounts of alcohol, as the man regularly did.
“Ethanol impairs consciousness and blunts protective reflexes (e.g., cough and gag), which disrupts the normal control mechanisms of the upper aerodigestive tract,” Dhaliwal noted.
And this is where Dhaliwal made a critical connection. If the man’s drinking led him to develop aspiration pneumonia—accidentally getting food in his lungs—he may have also accidentally gotten nonfood in this gastrointestinal tract at the same time.
Critical connection
The things people most commonly swallow by accident include coins, button batteries, jewelry, and small bones. But these things tend to show up in imaging, and none of the imaging revealed a swallowed object. Things that don’t show up on images, though, are things made of plants.
“This reasoning leads to the search for an organic object that might be ingested while eating and drinking and is seemingly harmless but becomes invasive upon entering the gastrointestinal tract,” Dhaliwal wrote.
“The leading suspect,” he concluded, “is a wooden toothpick—an object commonly found in club sandwiches and used for dental hygiene. Toothpick ingestions often go unnoticed, but once identified, they are considered medical emergencies owing to their propensity to cause visceral perforation and vascular injury.”
If a toothpick had pierced the man’s duodenum, it would completely explain of all the man’s symptoms. He drank too much and lost control of his aerodigestive tract, leading to aspiration that caused pneumonia, and he then swallowed a toothpick, which perforated the duodenum and led to sepsis.
Dhaliwal recommended an endoscopic procedure to look for a toothpick in his intestines. On the man’s third day in the hospital, he had the procedure, and, sure enough, there was a toothpick, piercing through his duodenum and into his right kidney, just as Dhaliwal had deduced.
Doctors promptly removed it and treated the man with antibiotics. He went on to make a full recovery. At a nine-month follow-up, he continued to do well and had maintained abstinence from alcohol.
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