Written by Dr. Stephanie Serrato (PGY3), Dr. Nora McNulty (PGY4), and Dr. Michelle Montenegro
38-year-old male with past medical history of opioid use disorder on methadone as well as unprovoked subsegmental pulmonary embolism (PE) on Eliquis presenting with chest pain, and shortness of breath x 3 days. He described the pain as a substernal stabbing/squeezing that is 7/10, constant, non-exertional and non-pleuritic. He presents to the emergency department today after a witnessed syncopal event associated with nausea, 2 episodes of non-bloody, non-bilious emesis, and shortness of breath. Patient endorsed smoking 3 cigarettes daily. He denied alcohol or other illicit drug use.
On physical exam, our patient was well-appearing and in no acute distress. Eating during interview. Breathing comfortably on room air. Cardiovascular exam was notable for regular rate and rhythm. Normal S1 and S2 with no murmurs, rubs or gallops. Distal pulses 2+ and symmetric on upper and lower extremities. His chest clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Case Discussion:
On arrival, our patient denied having active chest pain, however, given the history of unprovoked pulmonary embolism and symptoms of chest pain, shortness of breath, and syncope, concern for pulmonary embolism was high. As a result, CT PE and acute coronary syndrome work-up were pursued.
EKG showed NSR with no ST segment elevations or depressions as well as no signs of ischemia, and initial troponin was within normal limits. CT PE study was negative for PE; however, the study did demonstrate numerous cylindrical densities within the stomach, suggestive of pills or other foreign bodies (Figure 1).
Figure 1: CT Angiogram Chest notable for numerous cylindrical bodies within the stomach.
At this time, the patient was taken aside and questioned about possible ingestions. He reported only taking medications given to him at his rehab facility. He demonstrated immediate concern and adamantly denied any intentional ingestion of pills or other foreign objects. He also denied suicidal or homicidal ideation.
When asked what he had eaten today, he listed having a blueberry donut, and various candies spread throughout the course of the day and while in the ER. The patient agreed to CT abdomen pelvis for further evaluation.
Figure 2: CT Abdomen Pelvis with multiple, tubular, hollowed-out foreign bodies within the stomach.
CT Abdomen Pelvis without contrast conducted hours after the initial CT PE demonstrated multiple new tubular, hollowed-out foreign bodies in the stomach along with the previously described short, hyper-attenuating bodies concerning for interval ingestion.
Radiology emergently contacted the ED team over concern that the patient was potentially ingesting medical supplies such as catheters or IV tubing. ED providers immediately went to the patient's bedside for reassessment and noticed an empty wrapper of sour straw candies.
Upon further evaluation of CT images, the sour straw candies seemed similar to the tubular structures reported. Radiology was immediately notified; they measured the foreign bodies and confirmed that the length and appearance of the sour straws were consistent with CT findings.
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