Spontaneous pneumomediastinum with pneumopericardium, surgical emphysema, pneumothorax, and epidural pneumotosis: A rare association
An 18-year-old male was admitted in emergency department complaining of gradual swelling on face, neck and chest, hoarseness of voice along with difficulty in breathing. He had no previous history of cough, fever, loss of weight, night sweating, recent trauma, vomiting, foreign body lodgment, and drug abuse. He was non-smoker and non-alcoholic.\nOn physical examination patient was afebrile, his pulse rate was 110/min, respiratory rate 18/min, blood pressure 130/86 mm of Hg, and arterial saturation (Spo2) was 95% on room air. On palpation trachea was central and there was subcutaneous emphysema on face, neck, and chest region. On chest auscultation, the air entry was normal on both sides. Other clinical examination was essentially normal. ECG showed sinus tachycardia. Chest X-ray revealed surgical emphysema in soft tissue over chest and neck []. His routine investigations and biochemical results including arterial blood gas analysis were normal. Erythrocyte sedimentation rate was 20 mm/first hour. Fibroptic laryngosopy was normal. Computed tomography (CT) scan of neck and thorax showed evidence of marked pneumomediastinum and pneumopericardium, mild bilateral pneumothorax with few sub-pleural emphymatous bullae in both upper lobes, marked soft tissue emphysema along anterior and lateral chest, and also in superficial and deep neck spaces. Superiorly, the soft-tissue emphysema was extending along right infratemporal fossa and masticular space. Few air foci were also seen in posterior epidural space in cervico-dorsal spine [Figures –]. Trachea, main bronchi, visualized portion of oesophagus, pharyngeal, and laryngeal air appeared normal. No obvious rent was seen. Echocardiography was inconclusive due to poor visualization of cardiac structures which was due to presence of air in mediastinum and subcutaneous emphysema.\nThe patient was managed conservatively with 100% oxygen inhalation, regular blood gas analysis, broad-spectrum prophylactic antibiotics, analgesic and bed rest in intensive care unit. Progress was uneventful. He was absolutely normal on follow-up examination.