A Case of Pneumomediastinum and Parapneumonic Effusions Following Pharyngeal Perforation Caused by Shouting
A 43-year-old man presented with a 2-day history of dyspnea and chest pain after shouting in a quarrel with his wife. He had presented to a local clinic with fever, cough, sputum, and odynophagia 3 days previously, and was treated for acute pharyngitis. Before the onset of symptoms, he was in good health and had no significant past medical history except for 50 pack-years smoking history. Vital signs on admission were blood pressure 120/70 mm Hg, heart rate 100/min, respiration rate 28/min, and body temperature 38.7℃. On physical examination, there was swelling and tenderness in the left cervical area. Crackles were noted in both cervical areas. Coarse breath sounds were noted in both lung fields, and crackles were noted in the left lower lung field.\nLeukocyte count was 13000/mm3 (85.2% neutrophils, 9.4% lymphocytes, 4.7% monocytes, 0.2% eosinophils), hemoglobin 13.0 g/dL, and platelet count 229000/mm3. The results of arterial blood gas analysis in room air were pH 7.491, PaCO2 25.2 mm Hg, PaO2 62.4 mm Hg, HCO3- 21.8 mmol/L, and SaO2 94.2%. Liver function tests were normal. Serum total protein was 6.5 g/dL, albumin 3.5 g/dL, blood urea nitrogen 20.0 mg/dL, creatinine 1.2 mg/dL, sodium 135 mmol/L, potassium 4.2 mmol/L, creatine phosphokinase 431 IU/L, lactate dehydrogenase 658 IU/L, and high sensitivity C-reactive protein 30.7 mg/dL. Urinalysis was normal.\nAn initial chest radiography showed linear air trapping parallel to the border of the trachea, bilateral pleural effusion that was more severe on the left side, and consolidations in both lower lungs (). A chest computed tomography (CT) scan revealed air collection around the airway and mediastinum, infiltration around the mediastinum, and bilateral pleural effusions ().\nLaryngoscopy was performed by an otolaryngologist, and a small pharyngeal perforation in the right side of the vallecula was seen. A cervical CT scan also showed lacerations in the same area (). Analysis of the pleural fluid on the left side was consistent with parapneumonic effusions (pH 8.0, red blood cell count 3840/mm3, white blood cell count 2880/mm3, neutrophils 95%, total protein 4.6 g/dL, albumin 2.5 g/dL, lactate dehydrogenase 27198 IU/L, glucose 27 mg/dL). Intravenous moxifloxacin was started. In addition, chest tubes were inserted on both sides and supplemental oxygen was administered. Laryngoscopy was repeated 2 days later, and the previously-noted small pharyngeal perforation was not seen. Blood and pleural fluid cultures were negative, but fever and leukocytosis persisted. Antibiotics were broadened to piperacillin-tazobactam and amikacin. Fifteen days after admission, a follow-up chest radiography showed resolution of air trapping around the mediastinum and regression of parapneumonic effusions. The patient's symptoms and laboratory results continuously improved, and the patient was discharged 29 days after admission.