therefore , the purpose of this work is to discuss possibilities and mechanisms of serious and grave multiple complications associated with purulent meningitis ( pneumorrhachis ) . based on the studied case , conclusion and recommendations that would animate the debate on the topic he was admitted in the emergency department for cephalalgia , fever , and frequent easy vomiting lasting 1 week duration . symptoms were associated to a puffiness of the face and dyspnea of level i according to sadoul classification . at admission , the blood pressure was 120/70 mmhg with a heart rate of 80 beats / min and a respiratory frequency of 24 cycles / min . the neurological examination objectified signs of meningeal irritation without any motor and sensory deficit . the pleuropulmonary examination found subcutaneous emphysema in the top part of the thorax and upper limbs extending to the cervical region and the face . associated air effusion syndrome was not evidenced . afterward , a lumbar puncture was performed and revealed a blurred liquid with predominant polynuclear neutrophils ( 80% ) . g / l ( with concomitant glycemia of 1.20 g / l ) ; total albumin level was 0.98 g / l , and the classical cerebrospinal fluid ( csf ) gram s stain and culture was negative . the immunochemistry study of lumbar puncture was in favor of meningitis diagnosis , which oriented to start the antibiotherapy . the routine biological and hematological studies included blood cells count and blood culture , ionogram , and sedimentation rate were found to be normal . the patient was treated using adequate antibiotherapy consisting of 2.0 g of ceftriaxone every 12 h. ceftriaxone dose was maintained at the meningitis rate of 100 mg / kg / day . the thorax x - ray showed a pneumomediastinum in the left paratracheal border along the left edge of the heart ; the image also showed subcutaneous emphysema without associated pneumothorax [ figure 1 ] . evermore , thorax ct scan confirmed all abnormalities described in the thorax x - ray and revealed the presence of air collection in the spinal canal between c7 and d6 levels [ figure 2 ] . the laryngoscopy , bronchoscopy , and digestive opacification did not show any abnormality in the respiratory - digestive tracts . these invasive gestures were achieved under general anesthesia without remarkable event . the clinical evolution within 48 h was marked by the occurrence of apyrexia , coupled with disappearance of the subcutaneous emphysema and the meningeal steepness . however , the neurological status of the patient worsened gradually ; a paraparesis occurred and was followed by a tetraparesis . the patient started with presenting neurovegetative disorders with hemodynamic instability which was in favor of central affection . afterward , a spinal magnetic resonance imaging ( mri ) was performed and showed a cervical medullary edema extending from c2 to c6 without any sign of spinal cord compression . this result was consistent with a general clinical profile of acute transverse myelitis [ figure 3 ] . the hemodynamic support consisted initially of administrating vasoactive drugs and dopamine then adrenaline since nor adrenaline was not available . the patient died within 15 days with a profile of vasoparalysis resistant to vasoactive drugs . facial thoracic x - ray showing the pneumomediastinum with a form of a left bordered paratracheal along the left edge of the heart and subcutaneous emphysema the thoracic computed tomography ( ct ) scan in axial slice of the dorsal spine showing a lateral pneumorrhachis , pneumomediastinum , and cutaneous emphysema spinal magnetic resonance imaging ( mri ) in sagittal view in t1 ( a ) and t2 ( b ) showing medullary edema extending from c2 to c6 initially described by gordon and hardman , in 1977 , pneumorrhachis is defined as the presence of air in the spinal canal , either in the intradural and/or extradural spaces . it is a very rare clinical entity and mostly asymptomatic ; hence most probably underdiagnosed . the first type is associated with degenerative , malignant , inflammatory , and infectious diseases , while the last variety is generally associated to epidural anesthesia , lumbar puncture , spinal surgery , or after a chest tube insertion . the most reported hypothesis in the literature consists of a mechanism involving an increased intrabronchial pressure that leads to alveolar rupture when enough gradient pressure is produced . afterwards , the air cumulated in the mediastinum separates the mediastinal pleura from the aorta and the parietal pleura from the rachis , and penetrates the epidural space through the conjugate foramina . additional mechanisms might result from severe asthma attack , coughing , or other efforts while the glottis is closed . more rarely , spontaneous pneumorrhachis occur after grave vomiting efforts that our patient expressed ; he manifested vomiting secondary to purulent meningitis . the association of spontaneous pneumorrhachis with a pneumomediastinum is quite rare and restricted to very few cases in the literature . to the best of our knowledge , the association of spontaneous pneumorrhachis with pneumomediastinum and transverse myelitis originating of purulent meningitis was never described in the literature . in our patient , we believe that the occurrence of a tetraparesis is not secondary to a spinal cord compression caused by the pneumorrhachis itself , since the level of the intramedullary hypersignal in the mri images and the clinical profile are supporting the diagnosis of a transverse myelitis associated to pneumorrhachis . this association was never described in earlier literature . firstly , both pneumorrhachis and transverse myelitis present are distinct complications of purulent meningitis evolving independently : pneumorrhachis was caused by alveolar rupture induced by thoracic hyper pressure provoked on its turn by emesis , while transverse myelitis is an independent complication of meningitis related to infectious and/or inflammatory disorders . secondly , pneumorrhachis and transverse myelitis have been closely laid : the pneumorrhachis has facilitated and/or anticipated the occurrence of spinal cord edema through inflammatory mechanisms or by compromising the venous drainage of the epidural veins . finally , both pneumorrhachis and transverse myelitis have been probably caused by gas - forming germs . nevertheless , this last hypothesis might be excluded considering the important size of the pneumomediastinum and the absence of typical signs of infectious mediastinitis . these consist of endoscopy exploration and digestive opacification excluding any esophageal rupture , tracheal branches perforation , or laryngeal fissure the ct scan remains the diagnostic tool of choice . however , x - ray radiography is helpful for initial exploration allowing the early detection of pneumorrhachis . most reports considered the benign course of spontaneous pneumorrhachis which is usually reabsorbed spontaneously and completely without causing any symptoms , and does not recur . indeed , yoshida et al . reported three observations of compressive pneumorrhachis complicated by lumbar radiculopathy , which were resolved spontaneously . however , in cases of secondary pneumorrhachis , prophylactic antibiotherapy is recommended to prevent meningitis . in case of symptomatic pneumorrhachis thus , raynor and saint - louis described a case of radicular compression secondary to a pneumorrhachis that occurred 10 days after a lumbar disk surgery ; in this case , the evolution was favorable using corticosteroid therapy . exceptionally , spinal surgery is required for releasing the spinal cord from the air bubbles . to date , there are no guidelines for the treatment of this clinical entity due to its extreme scarcity . in general in addition , the control of infection is more important for the prognosis of the patient . the association of spontaneous pneumorrhachis with pneumomediastinum and transverse myelitis was never reported in the literature . therefore , particular care must be undertaken when dealing with patients of such pathological profile . further reports might better lighten the mechanisms underlying this pathological association as well as the optimal treatment .