Case reports 2017; 3(2)
[Link]
Spontaneous pneumomediastinum.
Case report
Palabras clave: Enfisema mediastiníco, Enfisema subcutáneo.
Keywords: Mediastinal Emphysema; Subcutaneous Emphysema.
Laura Marcela Velásquez Gaviria, MD • Andrés Fernando Rodríguez Gutiérrez, MD
Sebastián Felipe Sierra Umaña, MD • Andrés Garcés Arias, MD
Department of Internal Medicine – Faculty of Medicine –
Universidad Nacional de Colombia
Bogotá – Colombia
Laura Salazar Franco • Luis David Sáenz Pérez
Sebastián Salinas Mendoza • Cristian Alejandro Castillo Rodríguez
Medical Program – Faculty of Medicine –
Universidad Nacional de Colombia
Bogotá – Colombia
Diego Fernando López Donato, MD Luisa Fernanda Patiño Unibio, MD
Department of Radiology Department de Internal Medicine
Faculty of Medicine Faculty of Medicine
Universidad Nacional de Colombia Pontificia Universidad Javeriana
Bogotá – Colombia Bogotá – Colombia
Corresponding author:
Sebastián Felipe Sierra Umaña
Universidad Nacional de Colombia
Bogotá – Colombia.
Email: sfsierrau@[Link]
Received: 8/10/2016 Accepted: 22/5/2017
Case reports Vol. 3 No. 2: 84-90
92
ABSTRACT 13 to 35 (3); a study by Cáceres et al. (4) re-
ported a similar incidence between men and
Introduction: Spontaneous pneumomedias- women. In 1944, Macklin et al. suggested
tinum (SPM) is defined as the presence of air that SPM originates after an alveolar rupture
in the mediastinum. It is a rare entity consid- caused by increased intrathoracic pressure,
ered benign and self-limiting, which mostly af- with subsequent passage of air into the in-
fects young adults. Its diagnosis is confirmed terstitium and bronchovascular tissues of the
through clinical and radiological studies. tracheobronchial tree (5).
The most frequent symptoms are chest
Case description: 21-year-old male patient pain, dysphagia, persistent cough and dyspnea,
with cough and greenish expectoration for four while risk factors include chronic obstructive
days, associated with dyspnea, chest pain, fe- pulmonary disease, asthma, and tobacco and
ver and bilateral supraclavicular subcutaneous illicit drugs use. In addition, precipitating fac-
emphysema. Chest X-ray suggested pneumo- tors such as nausea, vomiting, cough, upper
mediastinum, which was confirmed by tomog- respiratory tract infection and strenuous phys-
raphy. The patient was hospitalized for obser- ical exercise have been observed (3). SPM
vation and treatment. After a positive evolution, cases have also been reported as complica-
he was discharged on the sixth day. tions of pneumonia by influenza A (H1N1) in
children, mainly during the pandemic period of
Discussion: SPM is a differential diagnosis in this infection in 2009 (6).
patients with chest pain and dyspnea. Its prev- The goal of treatment is to control symp-
alence is lower than 0.01% and its mortality toms and may require observation. The length
rate is low. It should be suspected in patients of hospital stay varies from a few hours to sev-
with chest pain and subcutaneous emphyse- eral days (2,4). This article presents a SPM
ma on physical examination. Between 70 and case in a young adult.
90% of the cases can be identified by chest
X-ray, while confirmation can be obtained Case description
through chest tomography. In most cases it
does not require additional studies. 21-year-old male patient from Garagoa
(Boyacá), resident of Bogotá D.C. Colom-
Conclusion: SPM is a little known cause of bia, an industrial automation student, mestizo,
acute chest pain, and rarely considered as a socioeconomic stratum 3, who presented a
differential diagnosis; it is self-limited and has clinical picture of four days of evolution con-
a good prognosis. sisting of cough with greenish expectoration,
dyspnea, chest pain, and unquantified fever.
Introduction On physical examination he did not have re-
spiratory distress and his vital signs were nor-
SPM is defined as the presence of air in the mal. Bilateral supraclavicular subcutaneous
mediastinum without an apparent secondary emphysema, decreased vesicular murmur and
cause (1). It is rare, benign and self-limiting, bilateral intermittent wheezing were identified;
and affects mostly young adults with an av- no other abnormal findings were observed.
erage age of 25 years (2), ranging between The patient had no relevant medical history.
spontaneous pneumomediastinum
93
Based on the clinical and epidemiological suspected. Leukocytosis with neutrophilia
characteristics, an acute respiratory infection and mild oxygenation disorder was found in
of viral origin was considered; in addition, the requested paraclinical exams (Table 1),
due to the presence of subcutaneous em- while left chest and left supraclavicular soft
physema and alterations in pulmonary aus- tissues were observed on the chest radio-
cultation, spontaneous pneumothorax was graph (Figure 1).
Table 1. Paraclínical exams.
On admission Control at 72 hours
Leukocytes 14670 cell/mm3 Leukocytes 12150 cell/mm3
Neutrophils 13670 cell/mm3 Neutrophils 8240 cell/mm3
Hematogram Hemoglobin 17 g/dL Hemoglobin 16.7 g/dL
Hematocrit 48% Hematocrit 47.7%
Platelets 257000 cells/mm3 Platelets 264000 cell/mm3
pH 7.43 pH 7.43
PO2 55.8 mmHg PO2 62.6 mmHg
FiO2 0.24 FiO2 0.21
Arterial blood gas PCO2 35.6 mmHg PCO2 33.7 mmHg
PAFI 232.7 PAFI 297
HCO3 23.3 mmol/L HCO3 22.3 mmol/L
BE -0.4 mmol/L BE - 0.6 mmol/L
Source: Own elaboration based on the data obtained in the study.
Figure 1. PA chest x-ray: pneumomediastinum,
delimitation of anatomical structures allowing
a neat visualization of its contours (arrow).
Source: Own elaboration based on the data obtained in the study.
Case reports Vol. 3 No. 2: 84-90
94
Later, a chest tomography was performed, secondary to an acute respiratory infection of vi-
which showed air in the anterior, middle, pos- ral origin was diagnosed; the patient was main-
terior and superior mediastinum, reaching the tained under observation, and treatment includ-
lower neck (Figure 2). Due to the absence of ing oxygen through nasal cannula, respiratory
risk factors related to secondary causes, SPM therapy, analgesia and rest was indicated.
Figure 2. Chest tomography, coronal
plane: pneumomediastinum, presence of
infracarinal and paratracheal air (sepia
arrow). Left supraclavicular subcutaneous
emphysema is also observed.
Source: Own elaboration based on the data obtained in the study.
The patient improved during follow-up, 0.01% and has a recurrence rate of 1.6% per
period in which leukocytosis and oxygenation year (8,9). SPM is a differential diagnosis in
disorder were corrected (Table 1), and was patients with chest pain and dyspnea, and is
discharged after six days of hospitalization. believed to be caused by alveolar rupture due
Outpatient radiographic monitoring was re- to increased intraalveolar pressure (1,10);
quested and he was given recommendations therefore, its association with pneumothorax
and warning signs. The patient did not present is frequent, being found in 32% of patients
adverse drug reaction or other events during (11). In 44% of cases, patients have a history
hospitalization. of congestive lung disease, such as asthma,
chronic obstructive pulmonary disease, inter-
Discussion stitial disease, pulmonary fibrosis, pneumoni-
tis, among others (11).
Pneumomediastinum was first reported in The mean age at diagnosis is 25 years
1819 by René Laennec while spontaneous (11), similar to that of patients with sponta-
pneumomediastinum was described in 1939 neous pneumothorax (9). In 34% to 49% of
by Louis Hamman (7). Its incidence is less than the cases, precipitating factors, such as in-
spontaneous pneumomediastinum
95
haled drug abuse, acute respiratory infection, sign appear. The delimitation of the inner and
vomiting, asthmatic crisis and intense exer- outer wall of the bronchus is possible due to
cise are observed (9,11). the presence of intra and extraluminal gas,
The most common clinical manifesta- generating a double wall sign. The continu-
tions include chest pain (68-78.1%), dyspnea ous diaphragm sign is caused by air posterior
(28.1-44%), sore throat (14.1-28%) and cervi- to the pericardium.
cal pain (54.7%) (9,12). Furthermore, subcuta- Other radiological signs include subcu-
neous emphysema is the most frequent symp- taneous emphysema, radiolucent lines in the
tom in about 40 to 100% of patients (9,12,13); upper mediastinum, pneumoprepericardium,
in contrast, Hamman’s sign (systolic crackle “Naclerio V”, extrapleural air sign and, thymic
heard with a stethoscope at the left sternal bor- wing sign caused by the delimitation of the
der) is found in only 20% of cases (14,15). thymus in children (16,21). Chest tomogra-
Its presentation is usually masked be- phy delimits the extension of the pneumome-
cause of the low specificity of the symptoms diastinum, and provides information about its
and the lack of knowledge of this entity (16). etiology and differential diagnoses (21,22).
The diagnosis is made based on clinical man- In most cases studies that look for sec-
ifestations and radiological confirmation, in ondary causes are unnecessary, since, in gen-
addition to searching for triggers (4,17). 79% eral, there are no alterations of the respiratory
of the patients are diagnosed in the emer- or digestive tracts. Advanced diagnostic pro-
gency room, 11% in the critical care unit, 2% cedures, restricting diet, administering antibi-
during hospitalization, and 8% in outpatient otics and prolonging hospitalization stay are
consultations (11). not appropriate measures (19). SPM has a
Radiological studies of the thorax are im- good prognosis and can be treated conserva-
portant in the evaluation and exclusion of sec- tively (18), which has shown good results in
ondary causes (9), and are sufficient to con- different studies (2,9,19,23). Such treatment
firm the diagnosis (18). Not all patients with consists of analgesia, rest, oxygen and bron-
pneumomediastinum require contrast radio- chodilators (24).
graphic imaging, which is reserved for patients In theory, oxygen supplementation is of
who are suspected of having a tracheobron- great importance for treatment, regardless of
chial or esophageal injury, especially when the presence of an oxygenation disorder, since
vomiting, dysphagia, known gastrointestinal it increases the pressure of nitrogen diffusion
disease, trauma, fever, hemodynamic instabil- in the interstitium and promotes the absorption
ity, pleural effusion or pneumoperitoneum are of free air (16) accelerating the resolution time.
involved (19). The mean time of hospitalization is 4.6
Around 70% to 90% of SPM cases can days (9) and its management in a critical care
be identified by chest X-ray (20). The pres- unit is unnecessary unless required or in cas-
ence of mediastinal air creates an interface es in which esophageal rupture is highly sus-
with the anatomical structures that allows pected (19). Once the patient is discharged,
to visualize its contours neatly. Radiological radiological follow-up can be performed until
signs depend on the quantity and location of full resolution (16).
the air (21): when it surrounds the vascular The case described here corresponds
structures, the ring sign and the tubular artery to a patient, whose epidemiological, clinical
Case reports Vol. 3 No. 2: 84-90
96
and radiological characteristics are the most pneumomediastinum: 41 cases. Eur J Cardio-
frequently reported in the literature. This is a thorac Surg. 2007;31(6):1110-4. [Link]
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tic approach in young patients who present 2. Jougon JB, Ballester M, Delcambre F,
chest pain on arrival to the emergency room. Mac Bride T, Dromer CE, Velly JF. Assess-
It is important to mention that this case had ment of spontaneous pneumomediastinum: ex-
several limitations, including the lack of mi- perience with 12 patients. Ann Thorac Surg.
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logical control, and information on outpatient momediastinum: is this really a benign entity?
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momediastinum. However, this report is im- experience in 47 adult patients. Eur J Cardiothorac
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SPM is a rare entity that requires high clinical 5. Macklin MT, Macklin CC. Malignant interstitial
suspicion for both diagnosis and radiological emphysema of the lungs and mediastinum as an
confirmation. Its treatment is symptomatic important occult complication in many respiratory
and has a good prognosis. SPM should be diseases and other conditions: an interpretation
considered as a differential diagnosis in pa- of the clinical literature in the light of laboratory
tients with chest pain. experiment. Medicine. 1944;;23(4):281-358.
6. Hasegawa M, Hashimoto K, Morozumi
Conflict of interest M, Ubukata K, Takahashi T, Inamo Y.
Spontaneous pneumomediastinum compli-
None stated by the authors. cating pneumonia in children infected with
the 2009 pandemic influenza A (H1N1) vi-
Funding rus. Clin Microbiol Infect. 2010;16(2):195-9.
[Link]
None stated by the authors. 7. Hamman L. Spontaneous mediastinal emphy-
sema. Bull Johns Hopkins Hosp. 1939;64:1-21.
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