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      An Uncommon Cause of Spontaneous Pneumomediastinum and Subcutaneous Emphysema

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          Abstract

          A 79-year-old gentleman presented with spontaneous pneumomediastinum and subcutaneous emphysema with pneumonia but no pre-existing lung disease.

          He presented with a 4-day history of increased shortness of breath, pleuritic chest pain, fevers, and non-productive cough. After 4 days of intravenous antibiotics, the patient developed considerable subcutaneous emphysema and pneumomediastinum.

          Pneumomediastinum presents most commonly with chest pain, shortness of breath, and subcutaneous emphysema. It has previously been associated with cases of pneumonia but often with rare strains such as P. jirovecii pneumonia in immunocompromised patients. This case highlights spontaneous pneumomediastinum as a rare complication of pneumonia. Treatment of pneumomediastinum is typically conservative, and although options may be limited, aggressive management of any causative factor may be essential in selected cases.

          LEARNING POINTS
          • Pneumomediastinum and subcutaneous emphysema are rare complications of pneumonia.

          • Computerised tomography is a valuable diagnostic tool for identifying pneumomediastinum in patients with subcutaneous emphysema.

          • While pneumomediastinum is typically a benign condition, aggressive management may occasionally be required. Evidence regarding use of non-invasive/invasive ventilation remains limited but it may theoretically aggravate any air leakage.

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          Most cited references 4

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          Spontaneous pneumomediastinum: 41 cases.

          Spontaneous pneumomediastinum is characterized by the presence of interstitial air in the mediastinum without any apparent precipitating factor. The purpose of this study is to review and discuss our experience with this condition. A descriptive, retrospective study of 41 cases--34 men (83%) and 7 women (17%)--treated at our hospital for spontaneous pneumomediastinum from January 1990 through June 2006. The mean age of the patients was 21 years (range, 14-35 years). Notably, 22% of patients had a prior history of asthma. No precipitating factor was identified in 51% of cases while onset was associated with physical effort in 12%. Chest pain (85%) and dyspnea (49%) were the most common symptoms. Subcutaneous emphysema, which presented in 71% of patients, was the most common sign. Pneumomediastinum was diagnosed by plain chest radiography in all cases. In certain cases, a computed tomography scan of the chest, contrast-enhanced swallow, or bronchoscopy was performed. All patients were admitted to the hospital with good progress and no instances of morbidity or mortality. Treatment included analgesia, rest, and/or initial oxygen therapy. The mean length of hospital stay was 5 days (range, 1-9 days) with only one case of early recurrence, which was resolved satisfactorily. Spontaneous pneumomediastinum is a benign process primarily affecting young men. Despite its low incidence, spontaneous pneumomediastinum should be considered in the differential diagnosis of acute chest pain because it requires a high index of suspicion. Patients with spontaneous pneumomediastinum respond well to medical treatment, with no recurrence in the great majority of cases.
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            Pneumomediastinum.

            Pneumomediastinum is a condition in which air is present in the mediastinum. This condition can result from physical trauma or other situations that lead to air escaping from the lungs, airways or bowel into the chest cavity. Pneumomediastinum is a rare situation and occurs when air leaks into the mediastinum. The diagnosis can be confirmed via chest X-ray or CT scanning of the thorax. The main symptom is usually severe central chest pain. Other symptoms include laboured breathing, voice distortion (as with helium) and subcutaneous emphysema, specifically affecting the face, neck, and chest. Pneumomediastinum can also be characterized by the shortness of breath that is typical of a respiratory system problem. It is often recognized on auscultation by a "crunching" sound timed with the cardiac cycle (Hamman's crunch). Pnemomediastinum may also present with symptoms mimicking cardiac tamponade as a result of the increased intrapulmonary pressure on venous flow to the heart. The tissues in the mediastinum will slowly resorb the air in the cavity so most pneumomediastinums are treated conservatively.
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              Spontaneous pneumomediastinum: experience in 18 adult patients.

              Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum, developing in the absence of traumatic, iatrogenic, or preceding pulmonary pathologies (emphysema, chronic bronchitis, and lung cancer). The aim of this study was to review our experiences with SPM, underlining its symptomatology, diagnosis, treatment, and followup, and defining a reasonable course of assessment and management. A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in our institution between 1998 and 2005. Eighteen patients (10 males) were identified (average age = 25 +/- 4.8 years). Acute onset of chest pain was the predominant symptom at presentation. All patients developed clinically evident subcutaneous emphysema and underwent chest computerized tomography. Fiber bronchoscopy and echocardiogram were used selectively (8 patients). The average hospital stay was 6 (+/-1.4) days. Sixteen patients were conservatively treated, and only two patients were treated with thoracic drainage due to a related pneumothorax. The disease followed a benign evolution in all patients and, as of today, no relapse has been reported. SPM is an uncommon pathology with a usually benign course. The authors discuss SPM. A diagnostic algorithmic approach is necessary to rule out severe secondary entities and consequences that need urgent treatment.
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                Author and article information

                Journal
                Eur J Case Rep Intern Med
                Eur J Case Rep Intern Med
                European Journal of Case Reports in Internal Medicine
                SMC Media Srl
                2284-2594
                2017
                03 February 2017
                : 4
                : 4
                Affiliations
                [1 ]Foundation Year 2 Doctor, Aintree University Hospital, Liverpool, UK
                [2 ]Acute Medicine Consultant, Aintree University Hospital, Liverpool, UK
                Article
                549-1-3482-1-10-20170202
                10.12890/2017_000549
                6346762
                © EFIM 2017

                This article is licensed under a Commons Attribution Non-Commercial 4.0 License

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                pneumonia, subcutaneous emphysema, pneumomediastinum

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