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An Unusual Case of a Swallowed Thermometer Perforated in the Mediastinum
Ann Thorac Surg 2008;85:339 – 41
An Unusual Case of a Swallowed Thermometer Perforated in the Mediastinum Timothy Sakellaridis, MD, Konstantinos Potaris, MD, Dimitrios Mallios, MD, and Evangellos Sepsas, MD Second and First Department of Thoracic Surgery, General Hospital for Chest Diseases “Sotiria,” Athens, Greece
A 39-year-old woman, who was addicted to drugs, was admitted because of referred chest pain and dysphagia after deliberate ingestion of a thermometer in a suicide attempt 6 hours earlier. Rigid esophagoscopy was unrevealing. On awakening, the patient confessed that the thermometer had been swallowed more than a month be operated on and get narcotic pain medications. Her history disclosed multiple admissions and laparotomies after suicide attempts with swallowed thermometers in the last 3 years. (Ann Thorac Surg 2008;85:339 – 41) © 2008 by The Society of Thoracic Surgeons
M
etallic mercury has been used for centuries by physicians for the treatment of syphilis and tuberculosis. Accidental poisoning with liquid mercury (inorganic salts) is widely described in the literature as a result of cleaning wounds with mercury ointments, tattooing, broken thermometers, mercury-filled indwelling intestinal catheters, and blood sampling with mercury-sealed syringes. Occupational exposure to high urinary mercury excretion and intoxication by metallic mercury vapors and salts, in contrast to liquid mercury, have also been
Accepted for publication July 10, 2007. Address correspondence to Dr Potaris, Department of Thoracic Surgery, General Hospital for Chest Diseases, 152 Mesogion Ave, Athens, 115 27, Greece; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
339
noted to cause a chronic brain syndrome especially in hatters and furriers (the “mad hatters”) [1, 2]. Reports of suicide attempts with injected or ingested metallic or elemental mercury, resulting in multiple mercury pulmonary emboli and systemic emboli causing temporary abnormalities to other organs have been published [1, 3–5]. Cases of thermometers as foreign bodies accidentally penetrating the bladder or the rectum have also been reported. In this report, we describe a case of multiple suicide attempts by swallowing thermometers [6]. A 39-year-old white woman was admitted in the emergency department for chest pain and dysphagia after ingestion of a thermometer in a suicide attempt. She had been taking narcotics virtually since her teens. She was receiving psychiatric care. She gave a history of multiple admissions and laparotomies after suicide attempts with swallowed thermometers. She regarded these attempts as her best chance to obtain narcotic medications. On admission, she was conscious and alert, had normal breath and heart sounds, pulse rate, 110 beats/min; blood pressure, 110/50 mm Hg; respiratory rate, 30 breaths/ min; and temperature, 37.5°C. Her abdomen was soft and nontender, with many laparotomy scars. Results of laboratory examinations were within normal limits, except for white blood cells, which were 10.2 ⫻ 109/L (neutrophils, 81.6%). 〈 chest roentgenogram confirmed the presence of the swallowed thermometer in the mediastinum (Fig 1a), and an abdominal roentgenogram showed the presence of another broken thermometer in the bowel (Fig 1b). Because she originally claimed that the thermometer had been swallowed 6 hours before and had stuck in her chest, we proceeded with a rigid esophagoscopy to remove it from her esophagus. To our surprise, the thermometer was neither in the esophagus nor in the stomach. On recovering from anesthesia, the patient admitted swallowing the thermometer more than a month before and having lied again so she could be operated on and obtain narcotic pain medications. By reviewing her medical record, we found past abdominal roentgenograms showing intact thermometers in her bowel. We then ordered a chest computed tomography scan, which showed that the thermometer had moved to the mediastinum intact, and there were no signs of mediastinitis (Fig 2). She had an uneventful recovery, and the next day she was transferred to the psychiatric ward.
Comment The presented patient was a drug addict with severe depression and without any strong family or social support. She was not aware of mercury toxicity, but she intended to have a gastrointestinal perforation caused by the swallowed thermometers. We could not determine the reasons for her preference for thermometers. All previous swallowed thermometers had been removed intact, except for the last one that had broken in her bowel. The patient’s psychiatric manifestations predated 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.07.027
FEATURE ARTICLES
2. Oshikiri T, Morikawa T, Jinushi E, Kawakami Y, Katoh H. Five cases of lymphangioma of the mediastinum in adult. Ann Thorac Cardiovasc Surg 2001;7:103–5. 3. Wada A, Tateishi R, Terazawa T, Matsuda M, Hattori S. Case report: lymphangioma of the lung. Arch Pathol 1974;98: 211–3. 4. Shaffer K, Rosado-de-Christenson ML, Patz EF Jr, Young S, Farver CF. Thoracic lymphangioma in adults: CT and MR imaging features. Am J Roentgenol 1994;162:238 –9. 5. Wilson C, Askin FB, Heitmiller RF. Solitary pulmonary lymphangioma. Ann Thorac Surg 2001;71:1337– 8. 6. Enzinger FM, Weiss SW. Tumors of lymph vessels. In: Gay SM, ed. Soft Tissue Tumors. St. Louis, MO: Mosby;1995:679 – 700. 7. Lee CH, Kim YD, Kim KI, et al. Intrapulmonary cystic lymphangioma in a 2-month-old infant. J Korean Med Sci 2004;19:458 – 61. 8. Holden WE, Morris JF, Antonovic R, Gill TH, Kessler S. Adult intrapulmonary and mediastinal lymphangioma causing haemoptysis. Thorax 1987;42:635– 6. 9. Kim WS, Lee KS, Kim I, et al. Cystic intrapulmonary lymphangioma: HRCT findings. Pediatr Radiol 1995;25:206 –7. 10. Hilliard RI, McKendry JB, Phillips MJ. Congenital abnormalities of the lymphatic system: a new clinical classification. Pediatrics 1990;86:988 –94.
CASE REPORT SAKELLARIDIS ET AL SWALLOWED THERMOMETER
340
CASE REPORT SAKELLARIDIS ET AL SWALLOWED THERMOMETER
Ann Thorac Surg 2008;85:339 – 41
Fig 1. (a) A posteroanterior chest roentgenogram shows the presence of an intact thermometer in the mediastinum (arrow). (b) A roentgenogram of the abdomen shows the presence of a broken thermometer in the small bowel (arrow).
FEATURE ARTICLES
Fig 2. A computed tomography scan of chest shows the presence of an intact thermometer in the posterior mediastinum (arrow), without any signs of mediastinitis or pneumomediastinum.
the swallowing of mercury thermometers, so it was unlikely that her suicidal behavior could be attributed to mercury poisoning. In addition, she had no symptoms of systemic toxicity, which include nausea, vomiting, tremors, weakness, stomatitis, and neuritis. We also did not note pulmonary mercury emboli, which are observed on roentgenograms in most cases of mercury poisoning [1, 3–5]. This case is not consistent with the classic description of Münchhausen syndrome subtype of factitious disorder with co-occurring malingering. Although the patient deceived us to the point that we performed urgent endoscopy, she really had swallowed the thermometer. Drug addiction contributed to a malingered medicationseeking behavior, but her multiple suicide attempts were induced by depression [7].
The patient was lost to follow-up, but we were later informed that the thermometer in her mediastinum had been removed at thoracotomy in another hospital.
References 1. Chitkara R, Seriff NS, Kinas HY. Intravenous self-administration of metallic mercury in attempted suicide. Report of a case with serial roentgenographic and physiologic studies over an 18-month period. Chest 1978;73:234 – 6. 2. Barregärd L, Sällsten G, Conradi N. Tissue levels of mercury determined in a deceased worker after occupational exposure. Int Arch Occup Environ Health 1999;72:169 –73. 3. McFee RB, Caraccio TR. Intravenous mercury injection and ingestion: clinical manifestations and management. J Toxicol Clin Toxicol 2001;39:733– 8.
4. Givica-Perez A, Santana-Montesdeoca JM, Diaz-Sanchez M, Mmartinez-Lagares FJ, Castaneda WR. Deliberate, repeated self administration of metallic mercury injection: case report and review of the literature. Eur Radiol 2001; 11:1351– 4. 5. dell’Omo M, Muzi G, Bernard A, Filiberto S, Lauwerys RR, Abbritti G. long-term pulmonary and systemic toxicity fol-
CASE REPORT SAKELLARIDIS ET AL SWALLOWED THERMOMETER
341
lowing intravenous mercury injection. Arch Toxicol 1997;72: 59 – 62. 6. Kiriyama T, Motonaga I, Ichikawa T. Foreign body migration from the bladder. J Urol 1976;115:530 –1. 7. Hopkins RA, Harrington CJ, Poppas A. Münchhausen syndrome simulating acute aortic dissection. Ann Thorac Surg 2006;81:1497–9.
FEATURE ARTICLES
Ann Thorac Surg 2008;85:339 – 41
An Unusual Case of a Swallowed Thermometer Perforated in the Mediastinum Timothy Sakellaridis, MD, Konstantinos Potaris, MD, Dimitrios Mallios, MD, and Evangellos Sepsas, MD Second and First Department of Thoracic Surgery, General Hospital for Chest Diseases “Sotiria,” Athens, Greece
A 39-year-old woman, who was addicted to drugs, was admitted because of referred chest pain and dysphagia after deliberate ingestion of a thermometer in a suicide attempt 6 hours earlier. Rigid esophagoscopy was unrevealing. On awakening, the patient confessed that the thermometer had been swallowed more than a month be operated on and get narcotic pain medications. Her history disclosed multiple admissions and laparotomies after suicide attempts with swallowed thermometers in the last 3 years. (Ann Thorac Surg 2008;85:339 – 41) © 2008 by The Society of Thoracic Surgeons
M
etallic mercury has been used for centuries by physicians for the treatment of syphilis and tuberculosis. Accidental poisoning with liquid mercury (inorganic salts) is widely described in the literature as a result of cleaning wounds with mercury ointments, tattooing, broken thermometers, mercury-filled indwelling intestinal catheters, and blood sampling with mercury-sealed syringes. Occupational exposure to high urinary mercury excretion and intoxication by metallic mercury vapors and salts, in contrast to liquid mercury, have also been
Accepted for publication July 10, 2007. Address correspondence to Dr Potaris, Department of Thoracic Surgery, General Hospital for Chest Diseases, 152 Mesogion Ave, Athens, 115 27, Greece; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
339
noted to cause a chronic brain syndrome especially in hatters and furriers (the “mad hatters”) [1, 2]. Reports of suicide attempts with injected or ingested metallic or elemental mercury, resulting in multiple mercury pulmonary emboli and systemic emboli causing temporary abnormalities to other organs have been published [1, 3–5]. Cases of thermometers as foreign bodies accidentally penetrating the bladder or the rectum have also been reported. In this report, we describe a case of multiple suicide attempts by swallowing thermometers [6]. A 39-year-old white woman was admitted in the emergency department for chest pain and dysphagia after ingestion of a thermometer in a suicide attempt. She had been taking narcotics virtually since her teens. She was receiving psychiatric care. She gave a history of multiple admissions and laparotomies after suicide attempts with swallowed thermometers. She regarded these attempts as her best chance to obtain narcotic medications. On admission, she was conscious and alert, had normal breath and heart sounds, pulse rate, 110 beats/min; blood pressure, 110/50 mm Hg; respiratory rate, 30 breaths/ min; and temperature, 37.5°C. Her abdomen was soft and nontender, with many laparotomy scars. Results of laboratory examinations were within normal limits, except for white blood cells, which were 10.2 ⫻ 109/L (neutrophils, 81.6%). 〈 chest roentgenogram confirmed the presence of the swallowed thermometer in the mediastinum (Fig 1a), and an abdominal roentgenogram showed the presence of another broken thermometer in the bowel (Fig 1b). Because she originally claimed that the thermometer had been swallowed 6 hours before and had stuck in her chest, we proceeded with a rigid esophagoscopy to remove it from her esophagus. To our surprise, the thermometer was neither in the esophagus nor in the stomach. On recovering from anesthesia, the patient admitted swallowing the thermometer more than a month before and having lied again so she could be operated on and obtain narcotic pain medications. By reviewing her medical record, we found past abdominal roentgenograms showing intact thermometers in her bowel. We then ordered a chest computed tomography scan, which showed that the thermometer had moved to the mediastinum intact, and there were no signs of mediastinitis (Fig 2). She had an uneventful recovery, and the next day she was transferred to the psychiatric ward.
Comment The presented patient was a drug addict with severe depression and without any strong family or social support. She was not aware of mercury toxicity, but she intended to have a gastrointestinal perforation caused by the swallowed thermometers. We could not determine the reasons for her preference for thermometers. All previous swallowed thermometers had been removed intact, except for the last one that had broken in her bowel. The patient’s psychiatric manifestations predated 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.07.027
FEATURE ARTICLES
2. Oshikiri T, Morikawa T, Jinushi E, Kawakami Y, Katoh H. Five cases of lymphangioma of the mediastinum in adult. Ann Thorac Cardiovasc Surg 2001;7:103–5. 3. Wada A, Tateishi R, Terazawa T, Matsuda M, Hattori S. Case report: lymphangioma of the lung. Arch Pathol 1974;98: 211–3. 4. Shaffer K, Rosado-de-Christenson ML, Patz EF Jr, Young S, Farver CF. Thoracic lymphangioma in adults: CT and MR imaging features. Am J Roentgenol 1994;162:238 –9. 5. Wilson C, Askin FB, Heitmiller RF. Solitary pulmonary lymphangioma. Ann Thorac Surg 2001;71:1337– 8. 6. Enzinger FM, Weiss SW. Tumors of lymph vessels. In: Gay SM, ed. Soft Tissue Tumors. St. Louis, MO: Mosby;1995:679 – 700. 7. Lee CH, Kim YD, Kim KI, et al. Intrapulmonary cystic lymphangioma in a 2-month-old infant. J Korean Med Sci 2004;19:458 – 61. 8. Holden WE, Morris JF, Antonovic R, Gill TH, Kessler S. Adult intrapulmonary and mediastinal lymphangioma causing haemoptysis. Thorax 1987;42:635– 6. 9. Kim WS, Lee KS, Kim I, et al. Cystic intrapulmonary lymphangioma: HRCT findings. Pediatr Radiol 1995;25:206 –7. 10. Hilliard RI, McKendry JB, Phillips MJ. Congenital abnormalities of the lymphatic system: a new clinical classification. Pediatrics 1990;86:988 –94.
CASE REPORT SAKELLARIDIS ET AL SWALLOWED THERMOMETER
340
CASE REPORT SAKELLARIDIS ET AL SWALLOWED THERMOMETER
Ann Thorac Surg 2008;85:339 – 41
Fig 1. (a) A posteroanterior chest roentgenogram shows the presence of an intact thermometer in the mediastinum (arrow). (b) A roentgenogram of the abdomen shows the presence of a broken thermometer in the small bowel (arrow).
FEATURE ARTICLES
Fig 2. A computed tomography scan of chest shows the presence of an intact thermometer in the posterior mediastinum (arrow), without any signs of mediastinitis or pneumomediastinum.
the swallowing of mercury thermometers, so it was unlikely that her suicidal behavior could be attributed to mercury poisoning. In addition, she had no symptoms of systemic toxicity, which include nausea, vomiting, tremors, weakness, stomatitis, and neuritis. We also did not note pulmonary mercury emboli, which are observed on roentgenograms in most cases of mercury poisoning [1, 3–5]. This case is not consistent with the classic description of Münchhausen syndrome subtype of factitious disorder with co-occurring malingering. Although the patient deceived us to the point that we performed urgent endoscopy, she really had swallowed the thermometer. Drug addiction contributed to a malingered medicationseeking behavior, but her multiple suicide attempts were induced by depression [7].
The patient was lost to follow-up, but we were later informed that the thermometer in her mediastinum had been removed at thoracotomy in another hospital.
References 1. Chitkara R, Seriff NS, Kinas HY. Intravenous self-administration of metallic mercury in attempted suicide. Report of a case with serial roentgenographic and physiologic studies over an 18-month period. Chest 1978;73:234 – 6. 2. Barregärd L, Sällsten G, Conradi N. Tissue levels of mercury determined in a deceased worker after occupational exposure. Int Arch Occup Environ Health 1999;72:169 –73. 3. McFee RB, Caraccio TR. Intravenous mercury injection and ingestion: clinical manifestations and management. J Toxicol Clin Toxicol 2001;39:733– 8.
4. Givica-Perez A, Santana-Montesdeoca JM, Diaz-Sanchez M, Mmartinez-Lagares FJ, Castaneda WR. Deliberate, repeated self administration of metallic mercury injection: case report and review of the literature. Eur Radiol 2001; 11:1351– 4. 5. dell’Omo M, Muzi G, Bernard A, Filiberto S, Lauwerys RR, Abbritti G. long-term pulmonary and systemic toxicity fol-
CASE REPORT SAKELLARIDIS ET AL SWALLOWED THERMOMETER
341
lowing intravenous mercury injection. Arch Toxicol 1997;72: 59 – 62. 6. Kiriyama T, Motonaga I, Ichikawa T. Foreign body migration from the bladder. J Urol 1976;115:530 –1. 7. Hopkins RA, Harrington CJ, Poppas A. Münchhausen syndrome simulating acute aortic dissection. Ann Thorac Surg 2006;81:1497–9.
FEATURE ARTICLES
Ann Thorac Surg 2008;85:339 – 41