Siphoning diesel: a fatal mistake.

Diesel is commonly used as fuel for engines and is distilled from petroleum. Diesel has toxic potential and can affect multiple organs. Exposure can occur after ingestion, inhalation or through the dermal route. The practice of siphoning diesel using a rubber tubing and the mouth is common in rural communities. This can lead to accidental ingestion and aspiration. Here we report a case of a patient who accidentally ingested diesel during siphoning, which caused extensive erosion of the oral cavity and oesophagus leading to pneumomediastinum and severe chemical lung injury. The patient responded well initially to steroids and supportive care but required prolonged hospitalisation. He developed complications of nosocomial infection and succumbed 23 days after admission.

The usefulness of a bilateral trans-cervical pneumomediastinal approach for mediastinoscopic radical esophagectomy: a right transcervical approach is an available option.

OBJECTIVE: We investigated the merits and demerits of right cervical open surgery with right trans-cervical pneumomediastinal approach in mediastinoscopic esophagectomy. METHODS: Ten thoracic esophageal cancer patients were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. RESULTS: The average number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without using the right trans-cervical pneumomediastinal approach, it might be impossible to successfully remove some of the right cervical and upper mediastinal paraesophageal lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes lymph nodes. Regarding surgical complications, one case of bilateral recurrent nerve palsy as well as two cases on the right and two cases on the left were noted. CONCLUSIONS: Although the rate of recurrent nerve palsy should still be reduced, a bilateral (especially right-sided) trans-cervical pneumomediastinal approach is an available option for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

Mediastinal Parathyroidectomy Using a Cervical Approach Under a Pneumomediastinum.

Video-assisted thoracoscopic surgery (VATS) and robotic surgery are minimally invasive surgeries for mediastinal parathyroid adenomas. However, a transthoracic approach is often difficult in the cervicothoracic transition area because of the limited visual field. We report a novel minimally invasive surgery for an ectopic parathyroid adenoma in the middle mediastinum using a cervical approach under a pneumomediastinum.

Neumomediastino espontáneo. Reporte de un caso / Spontaneouspneumomediastinum. Case report

RESUMEN El neumomediastino espontáneo se caracteriza por la presencia de aire en el mediastino. Es una enfermedad generalmente benigna, que evoluciona de forma satisfactoria entre 2 y 15 días, no asociada a causa directa conocida. Es infrecuente en la tercera edad. Se presenta principalmente con dolor torácico, disnea y enfisema subcutáneo. El diagnóstico se realiza sobre la base del cuadro clínico, la radiografía de tórax y la tomografía axial computarizada de tórax, siendo esta última importante, además, para establecer el diagnóstico diferencial con el síndrome de Boerhaave de manera oportuna. Se presentó el caso de un paciente masculino de 67 años de edad, fumador con antecedente de enfermedad pulmonar obstructiva crónica, que acude al cuerpo de guardia por dolor torácico, disnea y enfisema subcutáneo después de un episodio de tos intensa. Se le realizaron radiografías de tórax posteroanterior y lateral, en las que se observan la presencia de aire en el mediastino, se descartan otras enfermedades agudas, y se corrobora el diagnóstico de neumomediastino mediante tomografía axial computarizada de tórax. Recibió tratamiento con oxígeno, broncodilatadores, esteroides y antibióticoterapia, obteniéndose una mejoría evidente. La literatura reporta que no es habitual la presencia de este cuadro en pacientes de la tercera edad, y que debe sospecharse en aquellos que presenten una exacerbación de la enfermedad pulmonar obstructiva crónica, fundamentalmente después de un episodio de tos.

ABSTRACT The spontaneous pneumomediastinum is characterized by the air presence in the mediastinum. It is a generally benign disease which evolves in a satisfactory way between 2 and 15 days, that is not associated to any directly known cause. It is infrequent in the old age. It mainly presents with chest pain, dyspnea and subcutaneous emphysema. Diagnosis realizes on the base of clinical characteristics, thorax radiography and thorax axial computed tomography, being the last one also important to establish the differential diagnosis with Boerhaave syndrome in an opportune way. The case presented is the case of a male patient aged 67 years, who smokes and has antecedents of chronic obstructive pulmonary disease. He assisted to the consultation due to thoracic pain, dyspnea and subcutaneous emphysema after an episode of intense cough. Posteroanterior and lateral thorax radiography were done, finding air presence in the mediastinum; other acute diseases were discarded and the diagnosis of pneumomediastinum was corroborated through thorax computed tomography scan. He was treated with oxygen, bronchodilators, steroids and antibiotics therapy, obtaining an evident improvement. The literature reports that the presence of these characteristics in old-aged patients is not common and that it must be suspected in those presenting an aggravation of the chronic obstructive pulmonary disease, mainly after a cough episode.

Neumomediastino espontáneo en paciente con COVID-19 / Sponteneous pneumomediastinum in patient with COVID-19

Introducción: El neumomediastino espontáneo o síndrome Hamman es una complicación poco frecuente y rara. Se define como la presencia de aire o gas dentro del mediastino sin una causa identificada. Objetivo: Presentar un caso clínico con una complicación poco frecuente, neumomediastino espontáneo, en un paciente con enfermedad por COVID-2019. Caso clínico: Paciente de 86 años con cuadro clínico manifestado por fiebre de 38o C y síntomas respiratorios (tos con secreción blanquecina, disnea de moderados esfuerzos). Se realiza prueba de reacción en cadena de polimerasa para enfermedad por coronavirus 2019, esta fue positiva. Al cuarto día de su hospitalización concurre con empeoramiento clínico dentro que lo destaca tos y disnea progresiva acompañado con saturación de oxigeno menor a 91 por ciento. Se realizaron estudios imagenológicos de alta resolución (angiotomografía computarizada de tórax) en la cual se evidencia la presencia de neumomediastino. Desarrollo: La pandemia por enfermedad por coronavirus 2019 ha dado lugar a una emergencia de salud pública a nivel mundial, en la que es importante que el personal de la salud esté familiarizados con los síntomas, los resultados de imágenes y con las complicaciones de esta enfermedad, como el neumomediastino encontrado en este caso. Conclusión . El neumomediastino espontáneo es una complicación poco frecuente que se presenta en la fase inflamatoria de esta enfermedad(AU)

Introduction: Spontaneous pneumomediastinum or Hamman syndrome is a rare and infrequent complication. It is defined as the presence of air or gas within the mediastinum without an identified cause. Objective: To report a clinical case of spontaneous pneumomediastinum in a patient with COVID-2019, a disease with a rare complication. Clinical case report: We report the case of an 86-year-old patient with a clinical condicion of fever of 38o C and respiratory symptoms (cough with whitish secretions, dyspnea on moderate exertion). He underwent a polymerase chain reaction test for coronavirus disease 2019, which resulted positive. On the fourth day of his hospitalization, he his clinical condition worsened, including cough and progressive dyspnea accompanied by oxygen saturation less than 91 percent. The presence of pneumomediastinum was revealed by high-resolution imaging studies (computed tomography angiography of the chest). Discussion: The 2019 coronavirus disease pandemic has given rise to a global public health emergency, which requires health personnel to be familiar with symptoms, imaging results, and complications of this disease, such as pneumomediastinum found in this case. Conclution: Spontaneous pneumomediastinum is a rare complication that occurs in the inflammatory phase of this disease(AU)

Clinical presentation of air leak in an infant with undiagnosed cystic fibrosis: a case report.

INTRODUCTION: Air leak is a well-recognized complication of advanced cystic fibrosis in older children and adults but is extremely rare in infants. To the best of our knowledge, this is the youngest reported pediatric case of an air leak from a major airway. CASE PRESENTATION: A 4-month-old Yamani baby girl with a family history of cystic fibrosis initially presented with a history of a persistent paroxysmal cough for 3 weeks and vomiting for 1 week. Laboratory evaluation indicated pseudo-Bartter's syndrome. Imaging showed a tracheal tear with pneumomediastinum and subcutaneous emphysema that was treated conservatively. CONCLUSIONS: This case highlights the possibility of air leak in the population of young patients with cystic fibrosis and it shows a successful conservative management of tracheal tear. Physicians should consider cystic fibrosis in infants presenting with air leak.

[Thoracoscopic thymectomy with carbon dioxide insufflation in the mediastinum]. / Timectomía toracoscópica con insuflación de dióxido de carbono.

The case is presented of a 71 year-old male, diagnosed with a thymoma. A thoracoscopic thymectomy was performed using the carbon dioxide insufflation technique in the mediastinum. During the procedure, while performing one-lung ventilation, the patient's respiration worsened. The contralateral lung had collapsed, as carbon dioxide was travelling from the mediastinum to the thorax through the opened pleura. Two-lung ventilation was decided upon, which clearly improved oxygenation in the arterial gases and airway pressures. Both pH and pCO2 stabilized. The surgical approach and the carbon dioxide technique were continued because 2-lung ventilation did not affect the surgical procedure. This technique has many serious complications and it should always be performed using 2-lung ventilation.

Histioeosinophilic granulomas in the thymuses of 29 myasthenic patients: a complication of pneumomediastinum.

Nodular aggregates of histiocytes and eosinophils, described as "histioeosinophilic granulomas," were found in the capsules and septa of 29 of 63 nonneoplastic thymuses (45 per cent) removed from patients with myasthenia gravis. The configurations and cytologic appearances of the lesions resembled those of eosinophilic granuloma, but a combination of morphologic, immunohistochemical, and ultrastructural studies failed to demonstrate a Langerhans' cell component in these lesions. This heretofore unrecorded thymic lesion might represent the thymic counterpart of a pleural process that has been described as "reactive eosinophilic pleuritis" in patients with spontaneous pneumothorax and was probably induced by diagnostic pneumomediastinum performed prior to thymectomy. It is of interest, however, that the presence of these granulomas was correlated with an increased probability of remission of myasthenic symptoms following thymectomy.

Thymic abnormalities and autoimmune diseases.

Autoimmune diseases such as ulcerative colitis (UC) and myasthenia gravis (MG) are frequently associated with thymic abnormalities. Thymus hyperplasia and/or thymoma have been demonstrated in all cases with both of these two diseases by pneumomediastinography (PMG). In the diseases of digestive organs from which we can easily obtain the local information through the endoscopic observation and biopsy specimens, lots of immunological abnormalities have been accumulated. Antibody-dependent cell-mediated cytotoxicity mechanism has been demonstrated to play an important role in the mucosal destruction in UC. In the peripheral blood level of this disease, immunological abnormalities have been demonstrated such as the presence of lymphocytes sensitized by certain antigens, autoantibodies and disturbances of lymphocyte subpopulations. In the level of the thymus, the retrovirus has been detected in the thymus epithelial cells. The supernatant of thymus epithelial cell culture (STEC) has the capability of differentiating human bone marrow cells and of facilitating disease-specific immune abnormalities. Moreover, the serum factors (thymus growth factor) discovered in the patients with UC and MG, have been demonstrated to alter the thymic environments. Therefore, it is postulated that thymectomy is beneficial to exclude these abnormalities and it has been evaluated to be very effective in UC and MG clinically. From these observations, it is thought to be important to investigate the immunological abnormalities of autoimmune diseases from the viewpoints of three immunological levels, the level of disease-specific organ, the peripheral blood level and the level of the thymus. And it is important that the therapeutic plans should be decided in the consideration of the abnormalities in each immunological level.

Lung cancer. The past twenty-five years.

On the occasion of this Fourth World Conference on Lung Cancer, I am privileged to present the opening keynote address. This presentation has been sponsored by the Ontario Cancer Treatment and Research Foundation. In 1952, the Foundation established an annual lectureship in memory of one of their prominent physicians. Dr. Gordon Earle Richards was one of Canada's pioneer radiologists and radiotherapists who was appointed Director of the Institute of Radiotherapy at Toronto General Hospital at a time when radium and high-voltage x-rays were just coming into common use for the treatment of malignant disease. He established an international reputation for his contributions to clinical radiotherapy, and was subsequently appointed Professor of Radiology at the University of Toronto. He was Managing Director of the Ontario Cancer Treatment and Research Foundation between 1945 and 1949. I wish to thank the Foundation for the privilege of presenting the 33rd Gordon Richards Memorial Lecture.

Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis.

To facilitate initial visualization and subsequent mobilization of the thymus, adjuvant pneumomediastinum was preoperatively induced in 4 patients who underwent video-assisted thoracoscopic thymectomy. Neither mortality nor technique-related morbidity was observed. This experience shows video-assisted thoracoscopic thymectomy to be a safe and reliable procedure. In addition, we believe that adjuvant pneumomediastinum seems to facilitate the dissection maneuvers and could shorten operative time.

The value of computed tomography in staging bronchogenic carcinoma: a changing role for mediastinoscopy.

Forty-one patients underwent operative staging for bronchogenic carcinoma following computed tomography of the mediastinum between August, 1982, and March, 1984. Twenty-seven patients were classified as Stage I preoperatively; in 2 of them, positive mediastinal nodes were found at thoracotomy. For the 14 patients in whom positive nodes had been identified by computed tomographic (CT) scanning, staging was unchanged as a result of the findings at mediastinoscopy or thoracotomy or both. In this series, computed tomography had a sensitivity of 89%, a specificity of 100%, and an overall accuracy rate of 95%. We conclude that mediastinoscopy is not needed in patients without evidence of mediastinal nodal enlargement by CT scan; when performed, it should be guided toward those nodes identified as positive.

Radiologic diagnosis of chest disease.

Our purpose has been to provide a cursory review of radiologic diagnosis of noncardiac chest diseases. We have discussed several important diagnostic problems using illustrative cases from our experience. Although we have emphasized the role of computed tomography in solving particularly difficult problems, we still believe that most of the proven conventional techniques provide the best, simplest, and most economical approach to many problems in chest diagnosis. It is also apparent that the overall imaging management of the patient requires a multifaceted approach. The complexities of diagnosis and patient management more than ever require a comprehensive dialogue between radiologist and surgeon. The ultimate beneficiary as far as these technologies and improvements in communications between physicians are concerned is the patient.

The extent of the inferior border of the thymus: a report of two cases in infants.

Two cases of air insufflation of the mediastinum are reported to define the extent of previously unreported prolongation of the right thymic lobe occasionally seen in the normal infant chest radiograph.

[Evaluation of the pneumomediastinum for the diagnosis of tumours in the anterior mediastinum(author's transl)]. / Zur Wertigkeit des Pneumomediastinum bei der Diagnostik von Tumoren im vorderen Mediastinum

Using a correct retrosternal technique, adequate insufflation of negative contrast material and good radiography, a pneumo-mediastinum is the method of choice for the investigation of retrosternal tumours with respect to their position, size and shape. By means of experiments on cadavers, a suitable needle was developed. The method of air insufflation and radiographic positioning are described. The results of our examinations are detailed and the method is discussed.

Sternberg-Reed-like cells in a pleural effusion secondary to pulmonary emboli with infarction: a cytological observation.

Cells resembling Sternberg-Reed cells were observed in a pleural effusion that was caused by pulmonary embolus with infarction. Although Hodgkin's disease was suggested on the basis of abnormal pleural fluid cytological preparations, the subsequent evaluation and clinical course did not support that diagnosis. We conclude that first, the cytological diagnosis of Hodgkin's disease should only be made when Sternberg-Reed-like cells are seen in association with a compatible clinical and cytological picture, and second, the cytological diagnosis of Hodgkin's disease or other malignancy should be made with caution in cases in which pulmonary infarction is present.

[Potentials of pneumomediastinography in precisely determining the degree of esophageal cancer spread]. / Vozmozhnosti pnevmomediastinografii v utochnenii stepeni rasprostraneniia raka pishchevoda.

The data presented evidence that parietography is a valuable adjunct to routine roentgenological examination. One of the most complicated problems to be solved by this technic is whether the tumor invaded the adjacent structures, and also its relation to the surrounding tissues and mediastinal organs.

[Experience with the operation of a device for roentgeno-endoscopic examination]. / Opyt ekspluatatsii ustroistva dlia rentgeno-endoskopicheskogo issledovaniia

An appliance for roentgeno-endoscopic investigation permitting rotation of the patient is made in the shape of a crable that turns through 130 degrees and is firmly held in all positions of the X-ray apparatus mounting. The appliance provides good conditions for a multifarious roentgenological control over the manipulations with the bronchoscope, catheters, biopsy instruments and allows it to perform selective bronchography, pneumomediastinography angio- and lymphography. The appliance facilitates the arrest of the intrabronchial hemorrhage after biopsy and does not hamper the performance of reanimation procedures in cases of cardiac arrest. The use of the appliance increases the irradiation (absorbed) dose to which the service staff is exposed at their workplace by no more than 10 per cent.

[Selective phlebography of the thymus gland with pneumomediastinum in patients with myasthenia gravis]. / Selektivnaia flebografiia vilochkovoi zhelezy v usloviiakh pnevmodediastinuma u bol'nykh miasteniei.

The authors describe the technique of selective phlebography of the thymus under conditions of pneumomediastinum. The investigation of the thymus in 40 patients with myasthenia enabled the authors to conclude that a preliminary administration of gas into the fatty tissue of the anterior mediastinum facilitated catheterization of the thymus veins and favoured a success of selective phlebography, elevated the reliability of differential diagnosis of tumorous and involutional changes of the thymus as well as tumors and portions of a dense fibro-fatty tissue of the anterior mediatinum. The method is characterized by a lower radiation load on the patient and is more economical.

[A case of complete absence of the left pericardium coexisting with straight back syndrome].

A case of complete absence of the left pericardium coexisting with straight back syndrome in a 30-year-old female is presented. She had been asymptomatic, but was referred to our hospital because of an abnormal finding on a chest X-ray obtained during a routine physical examination. The posteroanterior view of the chest X-ray showed displacement of the right and left cardiac border to the left and bulging of the left cardiac border. The lateral view showed loss of normal thoracic curvature and also demonstrated the straight back syndrome. Echocardiography showed paradoxical movement of the ventricle septum, hyperkinetic movement of the free wall of the left ventricle and enlargement of the right ventricle. Computed tomography and magnetic resonance imaging with an artificial pneumomediastinum clearly showed rotation of the heart into the left hemithorax, prominence of the pulmonary trunk and pneumopericardium. Hence the diagnosis of the complete absence of the left pericardium coexisting with straight back syndrome was made. Congenital defect or absence of the pericardium are rarely reported. Only about 120 cases have been described in Japan. Only a few cases have been diagnosed antemortem. Most of them were found by chance during operations or on installation of an artificial pneumothorax. We suggest that an artificial pneumomediastinum as well as a pneumothorax is useful for the diagnosis of the absence of the pericardium. This is the first reported case of a complete absence of the left pericardium coexisting with straight back syndrome.