Infectious Disease Alert Updates
April 1, 2017 6 minutes read
By Carol A. Kemper, MD, FACP
Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center
Dr. Kemper reports no financial relationships relevant to this field of study.
Take Those Pins Out of Your Mouth!
SOURCE: Pellegrini AJ, Carnuccio MT, Guillardot A, et al. Recurrent Pseudomonas aeruginosa bacteremia caused by an intracardiac toothpick. J Card Surg 2017;32:97-98.
Remember your mother telling you not to put pins in your mouth? (I still do it.) And my father still chews toothpicks. Accidental ingestion of foreign bodies may present a medical emergency, especially with sharper objects, which have the potential for perforation and bleeding of the gastrointestinal tract. Rarely, extraluminal migration of sharp objects can occur, and complicating bacteremia has been reported.
These authors describe a 42-year-old man who presented with acute shortness of breath, hemoptysis, and Pseudomonas aeruginosa bacteremia.The workup revealed an intracardiac mass adjacent to the moderator band in the right ventricle. He responded well to antibacterials, and the mass diminished in size on follow-up echocardiogram. He returned four months later with recurrent Pseudomonas bacteremia, and a repeat TTE showed a linear density in the same area of the right ventricle. Right atriotomy was performed, retrieving a 6.5 cm toothpick. Cultures of the toothpick yielded the same bacterium.
While accidental ingestion of sharp objects is most commonly due to chicken bones or fish bones, people occasionally swallow pins, needles, staples, paperclips, or toothpicks. A survey of 136 case reports of ingested toothpicks found gastrointestinal perforation occurred in 79%, including the esophagus (2%), stomach (20%), duodenum (23%), small intestine (18%), and large intestine (37%).1 Individuals presented with abdominal pain (82%), fever (37%), and nausea (31%). Most of these patients (74%) were males, with an average age of 52 years (range, 5-90 years). The mortality was 9.6%. Fifty percent of the patients were unaware they’d swallowed a toothpick.
Surprisingly, many people are not aware they’ve swallowed something sharp. One author suggested this was possibly because of alcohol ingestion, eating too quickly, or pharyngeal insensitivity. But, in the case of toothpicks, I keep thinking it’s because of those hidden, partly burnt toothpicks in your meat patties cooked over the barbecue (shouldn’t the chef count and remove them before serving?), like the 2005 case description of a toothpick that migrated into the pericardium, mimicking post-infarction rupture of the ventricle.2 The patient remembered eating meatball rolls secured with toothpicks at a barbecue the night before. Accidental ingestion of a foreign body should be considered in any patient with an acute abdomen, even if they do not recall swallowing something risky.
REFERENCES
- Steinbach C, Stockmann M, Jara M, et al. Accidentally ingested toothpicks causing severe gastrointestinal injury: A practical guideline for diagnosis and therapy based on 136 case reports. World J Surg 2014;38:371-377.
- Gelsomino S, Romagnoli S, Stefano P. Right coronary perforation due to a toothpick ingested at a barbecue. N Engl J Med 2005;352:2249-2250.
How Many Sex Partners Is “Too Many”?
SOURCE: Harper CR, Dittus PJ, Leichliter JS, Aral SO. Changes in the distribution of sex partners in the United States: 2002 to 2011-2013. Sex Transm Dis 2017;44:96-100.
Changing mores regarding sex have direct bearing on patterns of sexual behavior and frequencies of STDs. Recent data suggest that adults of both sexes in the United States are more accepting of the idea of extra-marital sex and may be more willing to engage in sex with a casual sex partner. And yet, there is no good evidence that people of any particular age are having more sex partners — they just may not be marrying them. Recent data from various surveys suggest that the average number of sex partners has remained fairly stable over the past 10-15 years — although the curve has a very long right-handed tail, meaning that a few men and women, of every age group, are having sex with a lot of people — and the graph is becoming increasingly skewed to the right.
Data from the National Survey of Family Growth in 2002 and 2011-2013 was reviewed for the reported number of lifetime opposite sex partners and the number of opposite sex partners in the previous year. Interestingly, the median number of opposite sex partners for both men and women during the previous year did not significantly change from 2002 to 2011-2013. Both men and women reported a stable median number of one partner for the previous year. Of the upper 5% of men, the median number of self-reported opposite sex partners within the previous year remained stable at three in 2011-2013, compared with a stable number of two partners for the upper 5% women (P = NS).
Men continue to have more self-reported lifetime partners than women, although the gap appears to be closing, and the difference between the sexes is no longer statistically significant. The overall median number of opposite sex partners for women increased from three to four from 2002 to 2011-2013, compared with a stable median figure of five for men. Those figures were pretty similar, regardless of ethnicity, education, or poverty level. The top 20% of women reported a median number of eight partners, and the top 5% reported a median of 20 partners, figures that have not changed much in those 10 years. However, the median number of partners for the top 20% of men increased from 12 to 15, and in the top 5%, that figure increased from 38 to 50. That “50” figure was similar for the upper 5% of men, regardless of ethnicity, educational level, or whether above or below the Medicaid threshold. The data also suggest that you accumulate more partners with advancing age — not all at once, like in your 20s.
So, the median number of self-reported opposite sex partners for men remained fairly stable during those 10 years, while the average number of opposite sex partners for the average woman may have increased a little (still not quite as many as their male counterparts, but the gap may be closing). The exception is that subset of men at the far right of the curve — who are engaging in sex with many more partners than before.
Of course, if you read Cosmo, you will know that men tend to inflate their number of sex partners and women tend to deflate theirs. So, maybe the difference between a median of four for women and five for men is actually the same? (You can also imagine sometimes it’s hard to remember them all — and then, there is that one guy you want to forget …)
Rinse that GC Right Out of Your Mouth
SOURCE: Chow EP, Howden BP, Walker S, et al. Antiseptic mouthwash against pharyngeal Neisseria gonorrhoeae: A randomized controlled trial and an in vitro study. Sex Transm Infect 2017;93:88-93.
These investigators examined whether standard over-the-counter Listerine mouthwash has an inhibitory effect on Neisseria gonorrhea both in vitro and in human subjects. An in vitro study was performed using serial dilutions of Listerine Cool Mint or Listerine Total Care, which were spiked with ~ 108 of a laboratory reference strain of N. gonorrhea, and cultured on gonococcal agar plates within one minute. Bacterial colony growth was counted for each dilution. Both types of mouthwash significantly inhibited bacterial growth — especially at dilutions of 1:2 and 1:4, where < 100 colony growth was observed.
Next, 196 men having sex with men (MSM) with untreated pharyngeal gonorrhea were recruited, and randomly assigned to gargle and rinse with either Listerine Cool Mint or a phosphate-buffered saline rinse for one minute. Cultures of both tonsillar and posterior pharynx were performed before and after gargling. Only 58 of the men had positive pharyngeal cultures before using the assigned solution, and were included in the analysis, including 33 assigned to Listerine and 25 assigned to saline. Five of these were HIV+, including four assigned to the Listerine group. Forty-three men had positive posterior pharynx cultures before rinsing, and 43 were positive from the tonsillar fossa. Following a one-minute saline rinse, 90% of those with positive pharyngeal cultures were still positive, and 70% of those with positive tonsillar cultures were still positive. In comparison, following a one-minute Listerine gargle, 57% of each group were culture-positive. Thus, a one-minute gargle and rinse with Listerine had a lower odds of having a positive culture compared with the saline group (OR, 0.56), although this result was not statistically significant in this smaller sample.
The question remains whether the daily use of Listerine gargles could reduce the risk of acquisition or the duration of gonococcal infection in real life. If Listerine can reduce the carriage of pharyngeal GC with even one rinse, then perhaps daily use could theoretically have a cumulative beneficial effect — and may even reduce penile GC in the MSM community.
Take Those Pins Out of Your Mouth!; How Many Sex Partners Is “Too Many”?; Rinse that GC Right Out of Your Mouth
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