Man gets drunk, wakes up with a medical mystery that nearly kills him

A 36-year-old man showed up to the emergency department of the Massachusetts General Hospital, severely unwell from a puzzling set of conditions. He had abnormalities in his lungs, intestines, blood, liver, and lymphatic system—and, of course, no single clear explanation. His case was such a riddle that a master clinician with an expertise in clinical reasoning was called in to help unravel it.

In a case report published today in the New England Journal of Medicine, the expert and the man's other doctors lay out the masterful medical deduction that explained his remarkable case—which had an entirely unremarkable cause.

It all started about two weeks before his hospital visit. A mild, dull pain had developed in the patient's right lower abdomen and back. Nine days later, a fever and body aches also developed. The next day, he went to urgent care, where clinicians gave him intravenous fluids and an intravenous pain reliever. His abdominal pain went away, and he was discharged. But the pain returned over the next few days, and with it came nausea and vomiting. He then started coughing and having trouble breathing.

Complex case

The day before his hospital visit, he went back to urgent care. He now looked unwell and his eyes were yellowing, his heart was racing, and his blood pressure was worryingly low, as was his oxygen saturation, at just 85 percent. Clinicians could hear crackling in his lungs, and his abdomen was more tender than ever. They sent him to the emergency department.

There, doctors confirmed what the urgent care had found, noting he was also coughing up tan mucus. They also looked at his medical history, which was relatively short. He was born in Central America, but he had lived in the US for 16 years. He worked in construction, lived in a Boston suburb with his partner and two children, and didn't seem to have any medical problems except a history of alcohol use disorder. He typically drank four to five beers a night during the week and up to a dozen a day during the weekends, though he said he hadn't been drinking during his illness.

Blood and urine tests found his platelet levels were extremely low, and there were signs of liver disease. Chest imaging showed haziness in his lungs, suggesting inflammation and infection. Computed tomography (CT) scans confirmed the lung findings but also showed an enlarged liver, thickened bile duct, multiple swollen lymph nodes, a contracted gallbladder, and a blood clot in the vein from his right kidney. On close inspection, there also seemed to be a bridge of soft tissue spanning his duodenum (the first part of the small intestine) and the right kidney. More lab results then came back showing bacteria growing in his blood.

Doctors admitted him to the hospital, started him on intravenous antibiotics, and transfused him with platelets. Magnetic resonance imaging (MRI) confirmed the blood clot and the odd soft tissue bridge. In his first hospital day, the lab identified the bacteria in his blood as Streptococcus anginosus, a bacterium that typically colonizes the upper respiratory tract but can cause infections when the opportunity arises—such as when there is an injury in the gastrointestinal tract.

Clinical reasoning

This is where the master clinician Gurpreet Dhaliwal of the University of California, San Francisco, came in. Dhaliwal could not identify a single diagnosis that could convincingly explain all the problems at once, so he reasoned out a causal pathway—a sequence of events that could explain it all.

He started with the most obvious part of the pathway—the man had developed sepsis, which tied the man's blood and liver findings with the identification of the bacteria in his blood. Because S. anginosus is linked to injuries in the gastrointestinal tract, he next turned to the strange soft tissue bridge between the duodenum and the right kidney. The duodenum was thickened, suggesting an injury or perforation. And the soft tissue bridge between that part of the intestine and the right kidney could have harbored the bacteria. An infection and inflammation there could also explain the clot. But what caused the duodenum injury to begin with?

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.