In the Soup: Caustic Ingestion from the Improper Consumption of a Self-Heating Soup
The patient is a 54-year-old male who opened a can of OnTech® Hillside tomato soup one morning after consuming a large, but unquantified amount of alcoholic beverages. The patient says he opened the top food-containing compartment of the canister and poured the soup into a bowl. He subsequently cut open the bottom calcium oxide containing compartment of the canister with a pocket knife and combined the powdered heating element with the soup. Upon consuming the mixture, he stated he began feeling an intense burning sensation in the back of his throat. It was at that time he also noted that the mixture was getting hard “like plaster.” He immediately drank a can of beer in an attempt to soothe the burning sensation.\nAbout 45 minutes after the ingestion he reported to the ED complaining of pain with swallowing that radiated into his chest. He denied drooling, hoarseness, dyspnea, abdominal pain, nausea, vomiting, diarrhea, or bloody stools. He also denied any recent illness or history of odynophagia or chest pain. He had medical history significant for hypertension, chronic obstructive pulmonary disease, gastroesophageal reflux disease (GERD), and anxiety. His medications included olanzapine, lisinopril, lorazepam, omeprazole, verapamil, fluoxetine, and zolpidem. He stated that he consumes an unquantified amount of alcohol daily, smokes occasional marijuana, and is a former tobacco smoker. His review of systems was negative except for the presenting complaints.\nOn physical exam the patient appeared uncomfortable, but was in no acute respiratory distress. His breath smelled of alcohol, but he was alert, oriented, and appeared clinically sober. He was acting and conversing appropriately with good insight. His presenting vital signs were a blood pressure of 152/74 mm Hg, a pulse of 92 beats per minute, respirations of 18 breaths per minute, an oral temperature of 98.20 F, and a room air pulse oximetry reading of 95%. He showed no external signs of trauma and was not drooling. He was noted to have mild erythema in the posterior oropharynx, with no edema, blistering or exudate. He was able to swallow water, but experienced severe pain doing so. His neck was supple with no jugular venous distention, his lungs were clear to auscultation, and his cardiac exam revealed normal heart tones without murmurs. His abdominal examination revealed normal bowel sounds, soft, nontender, no rebound or guarding, no organomegaly, and his stool was negative for gross or occult blood. On neurological examination he was alert and oriented to person, place and time with no focal deficits.\nAfter the initial history and physical exam, an intravenous (IV) line was placed and his pain was treated with intravenous fentanyl. A search of the product website revealed that the chemical powder contained calcium oxide, which forms calcium hydroxide and heat when mixed with water. This added concern for an alkali burn along with thermal burn. The Statewide Poison Control Center was contacted as it was not immediately clear what comprised the ingested powder. The Statewide Poison Control Center was not familiar with the product, but felt it may have contained an iron and charcoal compound that could produce an exothermic reaction when mixed with water. Their advice was to obtain a serum iron level, and treat the ingestion like a thermal burn.\nHe was found to have an iron level of 103 mcg/dl, a TIBC of 326 mcg/dl, a ferritin level of 131 ng/ml, a serum alcohol level of 135 mg/dl, a hemoglobin of 14.5 g/dl, a hematocrit of 42.0%, a total white blood cell count of 7, 900 cells/HPF, and platelets of 237,000. A comprehensive metabolic panel was normal except for slightly elevated glucose level of 167 mg/dl.\nA chest radiograph was obtained and showed a normal cardiac and mediastinal silhouette, with no pneumomediastinum or abdominal free air. A noncontrast chest computed tomography (CT) showed no evidence of esophageal perforation or abnormality. The patient continued to have worsening pain in posterior pharynx radiating down to the chest, as well as odynophagia not well controlled with intravenous narcotic pain medication. The case was discussed with the oncall gastroenterologist and he was consulted for an emergent esophagogastroduodenoscopy (EGD). During the bedside EGD, the patient was found to have no esophageal perforation and no transmural or deep esophageal injury. Mild posterior oropharyngeal irritation and a non-erosive gastritis was noted, and not believed to be related to the ingestion. The patient improved and was subsequently discharged home with sucralfate for 7 days and gastrointestinal (GI) follow up in 1 week, at which time he was lost to follow up.