SESSION TITLE: Miscellaneous Case Report Posters II
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Spontaneous pneumomediastinum (SPM) is defined as the presence of free air in the mediastinum. Preexisting lung diseases are identified in approximately 50% of patients with SPM and include asthma, COPD, and interstitial lung diseases. Associated pneumothorax may develop in 10% to 30% of patients, but doesn’t require any intervention mostly.
CASE PRESENTATION: A 23 year old male with history of Type-1 Diabetes mellitus and polysubstance abuse presented with sudden onset of substernal squeezing chest pain of one day duration associated with nausea and retching. Patient took heroin intravenously on the day of admission. Patient had associated complaints of polyuria, polydypsia over the last four days. On arrival, he was afebrile, blood pressure was 136/68mmHg, heart rate of 112/minute, respiratory rate of 14/min with 100% oxygen saturation on room air. His pertinent physical findings were bilateral clear breath sounds and venous track marks on his forearms. His initial laboratory results revealed evidence of diabetic ketoacidosis(DKA). Chest X-ray was within normal limits, but a computed tomography (CT) of chest detected multiple foci of pneumomediastinum (PM). Patient’s DKA was treated appropriately promptly with intravenous fluids and Insulin drip. Esophagogram and Upper gastrointestinal endoscopy ruled out esophageal perforation. On further questioning, patient confessed to injecting drugs via his external jugular veins while holding his breath to make the veins prominent. Patient was clinically monitored over the next couple of days and discharged home.
DISCUSSION: The incidence of SPM though rare in general population, is seen in a higher frequency in illicit drug abusers. The mechanism is postulated to be due to alveolar rupture with dissection of air towards the hilum and the mediastinum.This alveolar rupture can occur during deep inhalation of illicit drugs and also during Valsalva maneuver done to inject drugs into neck veins.
CONCLUSIONS: The clinical manifestations can vary from being asymptomatic to having symptoms such as chest pain, dyspnea. A high index of clinical suspicion is needed to make the diagnosis. CT of the chest is more sensitive than chest X-ray to detect SPM .In general SPM has a benign course and aggressive treatment approach has to be individualized. Mostly treatment of primary cause is warranted but supplemental oxygen therapy will hasten the absorption of the mediastinal air. When SPM becomes physiologically significant, it can produce life-threatening cardiovascular collapse. Treatment in these cases is to give small infraclavicular venting incisions to allow air release and chest tube placement for associated pneumothorax.
Reference #1: Shyamsunder AK, Gyaw SM.Pneumomediastinum: the Valsalva crunch. Md Med J. 1999 Nov-Dec;48(6):299-302.
Reference #2: Panacek EA, Singer AJ, Sherman BW, Prescott A, Rutherford WF.Spontaneous pneumomediastinum: clinical and natural history. Ann Emerg Med. 1992 Oct;21(10):1222-7.
DISCLOSURE: The following authors have nothing to disclose: Jose Antony Paul, Varun Kumar, Vinay Huliyar, Hasnain Bawaadam, Vinod Khatri, Kovid Trivedi, Salman Alim, Saurabh Chawla, Sivashankar Sivaraman
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