John E. Monaco, M.D.
Megan is seven and hates to wear shoes, especially indoors. So it was no surprise one day when she ran to her mother crying because she had stepped on something while walking across the family room rug. To her horror, Megan's mother found a piece of a toothpick protruding from between Megan's first and second toes. She immediately called her husband, Megan's father, who ran a shop not far from the house. He closed the shop, hurried home, and was surprised to find exactly what his wife had described. Between the first two toes of her right foot protruded the tip of a painted turquoise toothpick. Megan's dad took charge of the situation and pulled out the toothpick, or so he thought. He dressed the wound with antibiotic ointment and within hours it was as if nothing had happened.
Several weeks later, when Megan's family had all but forgotten about the incident, Megan complained to her mother that her toe had been hurting again. When Mom spread the toes to examine her, she was astounded to see a swollen, very red area between the two toes, as well as red streaking along the top of the foot. Her husband took a closer look and realized that he could still see the entrance wound from the toothpick accident three weeks earlier. He tried to explore the area but could not even touch it for the excruciating pain it caused. Megan's parents decided to take Megan to the hospital.
In the emergency room, an x-ray of the foot was taken, but nothing was seen. An orthopedic surgeon was consulted and, given the swelling and apparent abscess, decided to take Megan immediately to the operating room for what is called "incision and drainage" of the area. He expected to find pus but did not rule out the possibility of finding a portion of remaining foreign body (toothpick).
Once the area was opened, a large amount of purulent material (pus) drained from the area. In addition, and to his astonishment, the surgeon found something else. There, between the toes, resting up against the long bone (metatarsal) of her toe was about one inch of turquoise toothpick. It had been there for over three weeks. Not only was the soft tissue infected, but also it was clear that the bone was also inflamed.
Bone infection is referred to as osteomyelitis and is an important diagnosis. If there had simply been cellulitis (soft tissue infection), Megan would have required 10 days to two weeks of antibiotics, depending on the organism and how she responded. Osteomyelitis, however, especially in a growing child, is a serious matter. Six weeks of antibiotics were going to be required, and most, if not all, of this would need to be intravenous.
The treatment presented logistic problems for Megan, as it often does for kids. Obviously, simple peripheral IV lines will not last six weeks. In these cases, and whenever long-term antibiotic therapy is required, a PICC line (peripherally inserted central catheter) is often inserted. This is a line designed to begin in the peripheral vein and that ends up in the central circulation (either the subclavian vein or the superior vena cava). The catheter is very thin, like fine spaghetti, and is threaded in from the arm.
Theoretically, a PICC line is a great alternative, and sometimes kids can even be sent home with these lines for home IV antibiotic therapy. Practically, however, without adequate professional supervision, they can malfunction, become infected or even become dislodged. Personally, I am reticent to send a child home with a PICC line for an extended period of time, especially an active child like Megan, without the assurance of good home nursing care. This was to be the case with Megan, who would be discharged for home care as long as home nursing could be arranged.
While Megan was in the hospital, she kept a small specimen bottle by her bedside. She was all too happy to share it and its contents with any visitor. The first day I came to visit, she showed it to me. Inside was an approximately one-inch piece of turquoise wood, the toothpick. She smiled proudly as I examined it. "That was in my foot," she said grinning. "And Mama says from now on I need to wear shoes!" I'm sure she did, and I hope Megan will.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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