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Unusual Cause of Chest Pain in a Young Patient FREE TO VIEW

Gilmar Zonzin, MD; Silvio Guerra; Vinicius Agostinho; Marina Faria; Mariana Silva; Priscila Virgens
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Pneumology, Centro Universitário de Volta Redonda, Volta Redonda, Rio de Janeiro, Brazil

Chest. 2014;146(4_MeetingAbstracts):689A. doi:10.1378/chest.1993003
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SESSION TITLE: Pediatric Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Spontaneous pneumomediastinum, also known as Hamman's syndrome, is a condition that usually occurs in young patients, with a male-female ratio of 8:1 cases. The main mechanism is the spontaneous rupture of alveoli, which may occur by increased intra-alveolar pressure or by decrease in peripheral vascular pressure. The clinical picture may vary according to the amount of air extravasated and can include patients who are asymptomatic as well as cases of significant chest pain, severe dyspnea and even death due to conditions associated with hipertensive pneumothorax. The diagnosis is made by clinical history, physical examination and is confirmed by imaging exams. It has to be made differential diagnosis with other sources of air in the mediastinum, such as trauma, rupture of esophagus (Boerhaave syndrom), esophageal perforation and rupture of the tracheobronchial tree.

CASE PRESENTATION: LFGA , 14 years old, male, living in a inner city of Rio de Janeiro, Brazil, student. Patient sought emergency room complaining of sudden severe chest pain at the level of precordium, dry cough and mild dyspnea. He denied history of trauma, fever, sputum, relation of the pain with physical activity or emotional factors and perception of wheezing or similar symptoms. The pain did not worsen with inspiratory movement or compression of the chest wall, and the thoracic pain was classified as type C. He denied previous similar episodes. On physical examination he showed chest pain that does not radiated nor worsened with positioning, and exhibited changes in breath sounds in the form of crackles in anterosuperior thorax wall. Normal values of white blood cells, ESR and CPR. There was not any abnormality founded in the initial evaluation of the chest radiography. Requested electrocardiogram and cardiac enzymes, that were normal. Remained under observation in the emergency room, receiving analgesia and being monitored, with clinical stability being verified. Then, he was released and taken to the pulmonology department. With a cautious analyse of the previous chest radiography made, it was suspected the presence of thin air layer in mediastinal space, without producing mediastinal shift. Sought chest tomography, which confirmed the existence of pneumomediastinum. The patient reported to be bearer of childhood asthma, absent in clinical manifestations in this time. It was considered the possibility of spontaneous pneumomediastinum and it was decided internation in hospital, at first with conservative approach, without placement of chest tube.It was prompted endoscopy for evaluation of possible esophageal perforation, but the exam was normal. He showed progressive clinical improvement and disappearance of the pain, cough and dyspnea, being a total of seven days hospitalized using only analgesics. He was discharged asymptomatic, with ambulatory accompaniment, remaining since then uneventful .

DISCUSSION: The clinical case described presents an unusual cause of chest pain in a young patient, where a careful analysis of the plain chest radiography led to the suspicion of a rare etiology of this type of clinical presentation. Initial examinations were important to reduce the possibility of other etiologies and CT scan confirmed the initial clinical and radiological suspicion. Chest pain, even though is nonspecific, is the most associated symptom with spontaneous pneumomediastinum. Moreover, the presence of crackles in the precordium level is the signal of Hamman, uncommon but pathognomonic of this condition. Other crackles, as subcutaneous, can occur from infiltration of air into the cutaneous tissue, evidenced by palpation of this region. The tomography confirms the diagnosis when the chest radiography is insufficient or even normal.

CONCLUSIONS: It should be noted the nonspecific clinical presentation, compatible clinical features and absence of other more common sources of air in the mediastinum, as well an active pursuit of this etiologic possibility. It usually is a self-limited disorder, normally with no recorrence.

Reference #1: Yap V, Datta D.et al. Spontaneous pneumomediastinum.Chest. 2014

Reference #2: ALVES, G.R.T.; SILVA, R.V.A.; CORRÊA, J.R.M.; COLPO, C.M.; CEZIMBRA, H.M.; HAYGERT, C.J.P. Spontaneous pneumomediastinum (Hamman’s syndrome). J. bras. pneumol. v. 38, 2012.

Reference #3: PERNA, V.; VILÀ, E.; GUELBENZUA, J.J.; AMAT, I. Pneumomediastinum: is this really a beingn entity? When it can be considered as spontaneous? Our experience in 47 adult patients. European Journal of Cardio-thoracic. 2010.

DISCLOSURE: The following authors have nothing to disclose: Gilmar Zonzin, Silvio Guerra, Vinicius Agostinho, Marina Faria, Mariana Silva, Priscila Virgens

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