For days a woman complains of a strange stinging in her throat. During a television-viewing evening with her partner, she disappears briefly to go to the bathroom and does not come back. When the man looks for his girlfriend and enters the bathroom, he sees her lying on the floor, drenched in blood, with a wound on her head. What caused the woman to die?
Five days before her death, the 50 year-old had gone to the emergency department, because she felt a stinging in the throat – as if a foreign body were lodged in her throat. A laryngoscopy showed no abnormalities. An X-ray of the neck also showed nothing. The woman was sent back home thereafter. However, after four days, she reappeared in the emergency department due to dysphagia.
A blood analysis showed: leukocytosis (16.3 x 10⁹/ L) alongside neutrophilia (about 92%) and elevated C-reactive protein levels (38.90 mg /dL). Due to her medical history, the doctors also requested a psychiatric evaluation. The psychiatrist consulted was sure that it was a physical problem, given the woman's complaints and the results of the analysis. Eventually, the woman was prescribed a nasopharyngitis medication, with the recommendation to return if the symptoms worsen. A day later she died.
For a certain period of time, the long-time partner was suspected of murder; that however changed after an autopsy was carried out. Dr. César Lares dos Santos is one of the pathologists at the National Institute of Legal Medicine and Forensic Sciences in Portugal. Together with his colleagues, he examined the case more closely.
Pathologists on the wrong track
One question occupied the physicians: Why had the advice of a psychiatrist been obtained? From the partner of the victim they learned that she had been treated with medication in the past due a psychiatric disorder. The predominating view was that her problems related to the fact that she had been widowed years earlier. Mental illness, however, had nothing to do with the woman's complaints, as it turned out; the pathologists found a 3.5 cm long piece of wood in her oesophagus: a toothpick.
The woman's last meal had been salami sausages; she had it seems accidentally eaten a toothpick. "Traumatic lesions of the oesophagus are relatively uncommon in adults", Dos Santos is quoted as saying in the British daily newspaper The Sun. He assumes that the toothpick caused inflammation and led to heart failure.
Premature murder suspicion
"Sudden, unexpected deaths can give rise to baseless speculation, especially if blood is found at the scene", it says in the forensic case report. The woman hit her skull on the bathroom floor tiles when she collapsed. In addition, the glasses she was wearing caused further injuries to her face. "The victim had bleeding wounds and family members suspected the man, who had been a partner of the woman for six years, had committed the murder". At the autopsy, however, the pathologists noticed that the woman's neck was slightly greenish in colour.
After dissecting the neck and opening the oesophagus, they discovered the toothpick. The three-and-a-half centimetre piece of wood was lodged in the upper part of the neck and covered with pus. Two stab wounds in the neck wall were also discernible. By conducting a histopathological and microbiological examination they were able to demonstrate acute bilateral inflammation of the cervical tissue as well as Klebsiella oxytoca. The authors draw the following conclusion: inflammation triggered by the toothpick in the neck probably affected sensitive nerve structures, especially the vagus nerve, which ultimately led to cardiac arrest. They point out the unusual traumatic lesion in the upper oesophagus and underline how important it is to look closely at injuries.
In their document, they advise colleagues to exercise wariness and to avoid diagnostic bias, such as the psychiatric problems in a patient's past, as occurred in this case. Only in this way can one obtain the best possible evidence-based diagnosis, they write.
Text Source: Dos Santos et al. / Journal of Forensic and Legal Medicine
Image Source: Toa Heftiba, unsplash