[A Case of Drug-Induced Pneumomediastinum Preceding Interstitial Pneumonitis Onset during Treatment with a First-Line Regimen of GnP in a Patient with Unresectable Pancreatic Cancer].

BACKGROUND: The highest prevalence of drug-induced interstitial pneumonitis(IP)occurs in patients receiving antineoplastic agents, such as cytotoxic chemotherapeutic drugs, molecular targeted drugs, and immune checkpoint inhibitors. A certain period of the treatment for IP requires discontinuation of the anticancer therapy, resulting in progression of the malignant status. CASE: A 70-year-old man was incidentally diagnosed with locally advanced unresectable pancreatic cancer in the course of his treatment for ventricular dysrhythmia. After the insertion of a pacing instrument, he was ensured to be eligible to receive combination chemotherapy with gemcitabine and nab-paclitaxel(GnP)as the primary regimen. Shortly after the second course of GnP, the patient had high fever and developed pneumomediastinum 3 days prior to the onset of IP. The GnP treatment was suspended, and the IP was treated with pulse steroid therapy. The respiratory disorder took approximately 3 months to resolve; however, this concomitantly led to aggravation of the malignancy, which developed multiple metastases to the liver. The patient was no longer allowed to receive antineoplastic treatment. CONCLUSION: Although GnP may be a key regimen for the treatment of unresectable pancreatic cancer, patients should be closely monitored to ensure early detection of adverse events, such as interstitial pneumonia. Furthermore, drug-induced pneumomediastinum may be a precursor to the onset of interstitial pneumonia.

Pneumomediastinum in an Accidental Chlorine Gas Exposed Victim.

Chlorine is an irritant gas, which is implicated in inhalational exposures and can affect the respiratory system leading to complications. We report a case of a 38-year man who presented in the Emergency Department (ED) after exposure to chlorine gas due to an industrial accident. During the course of ED stay, he developed gradual difficulty in breathing, which on investigation, was found to be related to the complication of pneumomediastinum. The patient required endotracheal intubation, but was difficult to ventilate. Bilateral chest tube insertion was performed, which led to the resolution of the pneumothoraces. The emergency physicians should be aware of such a case so that they can intervene. Key Words: Chlorine, Emergency, Pneumomediastinum, Toxicity.

Severe spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema precipitated by pepper spray-induced acute laryngitis: a case report.

We report a patient with severe spontaneous pneumomediastinum (SPM), pneumothorax and widespread subcutaneous emphysema with acute epiglottitis after inhaling pepper spray. The effects of pepper spray, which is a lachrymatory agent, on the respiratory system have not been reported. Upper airway obstruction is not a well-described cause of SPM, with which subcutaneous emphysema and pneumothorax might coexist; thus, mechanical ventilation might be detrimental.

Tension pneumomediastinum from opioid inhalation.

Pneumomediastinum is a rare complication of substance use, likely due to a Valsalva maneuver after drug inhalation. There are no previously documented associations between pneumomediastinum and opioid use. A 30-year-old man with a history of recent heroin and fentanyl inhalation presented to the emergency department in respiratory distress requiring intubation. His course was complicated by pneumomediastinum which subsequently developed tension physiology. He required emergent surgical decompression with a "blowhole incision" to his anterior chest. Although a rare complication of polysubstance use, pneumomediastinum can progress to tension physiology, requiring prompt diagnosis and management.

Spontaneous pneumomediastinum in accidental chlorine gas inhalational injury: case report and review of literature.

A young man presented in emergency department with shortness of breath and cough after accidental inhalation of chlorine gas. Initial presentation was unremarkable; therefore, he was kept under observation for 8 hours and was later discharged. After 5 hours, the patient presented again in emergency department with sudden-onset shortness of breath and chest discomfort. On examination, subcutaneous crepitation around the neck and chest was found. Chest and neck X-ray revealed subcutaneous emphysema and pneumomediastinum. CT neck and chest was done, which revealed subcutaneous emphysema and pneumomediastinum and a linear air density in close approximation to right posterolateral wall of trachea at the level of superior margin of sternum was reported. These findings raised the possibility of tracheal injury which was later confirmed by fiberoptic laryngoscopy. The patient was intubated due to hypercapnic respiratory failure resulting from hypoventilation and respiratory distress. Bilateral chest tube insertion was done due to worsening subcutaneous emphysema, high ventilator parameters and prevention of progression to pneumothorax. He was extubated after 5 days; bilateral chest tubes were removed before discharge and underwent uneventful recovery.

[Pneumopericardium and pneumomediastinum caused by inhalation of laughing gas from a gas cartridge].

Laughing gas inhalation is frequently used for intoxication purposes. This case report describes a 25-year-old man, who suffered from both pneumopericardium and pneumomediastinum after having inhalated laughing gas. After three days of observation, he was discharged from hospital without any complications. Pneumopericardium and pneumomediastinum are very rare but potentially life-threatening complications of laughing gas inhalation.

Two Cases of Chloromethylisothiazolinone and Methylisothiazolinone-associated Toxic Lung Injury.

Previous animal studies have not conclusively determined the association between exposure to humidifier disinfectants (HDs) containing 5-chloro-2-methyl-4-isothiazolin-3-one (CMIT) and/or 2-methyl-4-isothiazolin-3-one (MIT) and development of HD-associated lung injuries. Nonetheless, patients exposed to HDs containing only CMIT and/or MIT showed clinically similar lung injuries to those exposed to HDs containing polyhexamethylene guanidine (PHMG) or oligo (2-[2-ethoxy]ethoxyethyl) guanidinium chloride (PGH). Here, we report twin sisters with lung injuries associated with exposure to CMIT/MIT-containing HDs. At 6 months of age, a younger twin sister presented with the 3-day history of cough, sputum, and respiratory difficulty. Chest radiography revealed multiple patchy consolidation and ground-glass opacities with pneumothorax and pneumomediastinum. Thoracostomy was performed due to pneumothorax at admission and she was discharged at 11 days of hospitalization. At 5 years of age, multiple tiny nodules and faint centrilobular ground-glass opacities were observed with the small pneumatocele. The elder sister visited a tertiary hospital due to dyspnea at 12 months of age. Chest radiography showed consolidation, pneumomediastinum, and pulmonary interstitial emphysema. There was no response to the administration of immunosuppressant drugs and antifibrotic agents. At 5 years of age, chest CT revealed ground-glass opacity and multiple tiny centrilobular ground-glass opacities nodules in both lungs with exercise intolerance.

Subcutaneous emphysema and pneumomediastinum following cocaine inhalation: a case report.

INTRODUCTION: Subcutaneous emphysema or pneumomediastinum can occur as a complication of illicit drug use although this is rare. When occurring without a pneumothorax and spontaneously, it is usually treated conservatively, but can have serious consequences. CASE PRESENTATION: Here, we present the case of an otherwise healthy 23-year-old Caucasian man who presented to the Emergency Department at our institution and was found to have both subcutaneous emphysema and pneumomediastinum as a result of cocaine use. His only presenting symptom was mild chest pain and he had palpable subcutaneous crepitations. He underwent a series of investigations including a chest radiograph and computed tomography as well as a barium fluoroscopy study to rule out secondary pneumomediastinum, which can be fatal. There were no other pulmonary features of illicit drug use, such as granulomas or fibrosis, seen on radiological imaging. He was subsequently managed with a period of observation and supportive care. CONCLUSION: We report a rare case of subcutaneous emphysema and pneumomediastinum likely due to the nasal insufflation of cocaine. We discuss the necessary investigations to rule out any serious underlying pathology. These should be considered in patients who present with chest pain after cocaine use.

[Conservative treatment improved corrosive esophagitis and pneumomediastinum in a patient who ingested bleaching agent containing sodium hypochlorite and sodium hydroxide].

A 69-year-old man was admitted to the emergency department 3 hours after ingestion of a bleaching agent containing hypochlorous acid and sodium hydroxide in a suicide attempt. Enhanced chest computed tomography scans taken on admission indicated an edematous esophagus and air bubbles in the mediastinum. He underwent endotracheal intubation and mechanical ventilation until day 9 because of laryngeal edema. On day 10, his endoscopy indicated diffuse reddish mucosal hyperemia, erosions, and lacerated mucosal lesions in the esophagus that were indicative of grade 2b corrosive esophagitis. Treatment with a proton pump inhibitor was initiated, with which the condition of the esophagus improved, and on day 44, a slight stricture of the upper part of the esophagus was observed. He was discharged on day 64 without any complaints. The ingestion of sodium hypochlorite induces corrosive esophagitis and acute phase of gastritis. Ingestion of any corrosive agent is known as a risk factor for esophagus cancer in the long-term. In such cases with esophageal stricture, esophagectomy is recommended for preventing esophagus cancer. Considering the age of the patient, however, he did not undergo esophagectomy.

[Spontaneous pneumomediastinum secondary to inhalation of crack]. / Pneumomédiastin spontanée secondaire à l'inhalation de crack.

The use of cocaine causes numerous cardiovascular and pulmonary side effects. In this context, the occurrence of a pneumomediastinum represents a specific complication, often misunderstood by primary care physicians. We describe here on case of patient who suffered from subcutaneous emphysema and pneumomediastinum after smoking "crack". We emphasize the importance of always keeping in mind the possibility of illicit substance use in such cases, especially among young and healthy patients. A short observation period with outpatient follow-up is appropriate in the majority of patients. Invasive procedures have a low yield and should be based on a high degree of clinical suspicion for esophageal rupture or bronchial tree laceration.

[A case of pneumomediastinum during BEP (bleomycin, etoposide, cisplatin) chemotherapy for testicular cancer].

We report a case of drug-induced pneumomediastinum by bleomycin in testicular cancer, which is extremely rare ; to our knowledge, only 3 cases have been reported. A 28-year-old man presented with a left testicular mass. He underwent radical left inguinal orchiectomy that demonstrated a seminoma, pT3N0M0. Ten months after surgery, para-aortic lymph node metastasis appeared, and he received three cycles of bleomycin, etoposide and cisplatin (BEP) chemotherapy. On day 13 of the fourth course of BEP, he complained of snowball crepitation of the neck and computed tomography revealed subcutaneous emphysema, extensive mediastinal air, and intraspinal air accumulation without pneumothorax. The pneumomediastinum and subcutaneous emphysema tended to deteriorate until 15 days after the onset of pneumomediastinum, but fortunately he had no signs or symptoms of infection. These findings resolved spontaneously after 1 month.

Pneumomediastinum from acute inhalation of chlorine gas in 2 young patients.

Trichloroisocyanuric acid is a high-efficiency and-low toxicity fungicide and bleach. It is commonly used as disinfectant for industrial circulating water, swimming pools, restaurants, and other public places in China. When trichloroisocyanuric acid is put into water, chlorine gas is produced. Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tracts (J Toxicol Clin Toxicol. 1998;36(1-2):87-93). Pneumomediastinum is a rare complication in patients with acute chlorine gas poisoning. A small amount of gas can be asymptomatic, but a large amount of gas entering the mediastinum suddenly will lead to respiratory and circulatory disorder, mediastinal swing, or even cardiopulmonary arrest. Severe chlorine gas poisoning patients usually need mechanical ventilation; if the pneumomediastinum is not found on time, threat to life would be greatly increased. It requires a high index of suspicion for diagnosis and rapid treatment. The proper use of ventilator, timely and effective treatment of original disease, and multiple system organ support had significant impact on the prognosis. The pneumomediastinum case secondary to inhalation of chlorine gas that we report here should remind all emergency department physicians to maintain a high index of suspicion for this disease and seek immediate and proper intervention when treating patients with acute chlorine gas poisoning, once diagnosed, especially in younger patients.

Neumomediastino espontáneo asociado al consumo de drogas inhalantes / Spontaneous pneumomediastinum as a complication of inhalant drug use

El neumomediastino es una entidad descripta por Hamman en 1939 y cuya patogenia fue establecida por Macklin en 1944(1). Se define por la presencia de aire en el mediastino y el carácter de espontáneo se lo otorga la ausencia de vinculación con otras patologías asociadas. Es una enfermedad benigna, infrecuente, autolimitada y que puede asociarse a neumotórax. Este trabajo presenta dos casos de neumomediastino espontáneo, sin neumotórax, en los cuales se destaca la concomitancia de inhalación de cocaína y pasta base de cocaína.

["Usual" cannabis abuse producing an unusual incident]. / "Gewöhnlicher" Drogenkonsum mit ungewöhnlichem Zwischenfall.

CASE HISTORY: A 17-year-old male presented in an agitated, deranged state with rapidly increasing swelling of the neck. Except for regular abuse of cannabis there was no medical history of note. He had a sinus tachycardia (130 bpm), a slow pupillary reflex, bilateral hyposphagma and subcutaneous emphysema around the neck and shoulders. INVESTIGATIONS AND DIAGNOSIS: Laboratory tests showed elevated inflammatory markers. The chest X-ray demonstrated a bilateral pneumothorax and large subcutaneous emphysema. Subsequent computed tomography of neck and thorax showed an extensive pneumomediastinum and the described subcutaneous emphysema. There was no evidence of a ruptured trachea or esophageal perforation. The underlying cause was presumed to have been a Valsalva maneuver during marijuana smoking. TREATMENT AND COURSE: As the pneumothorax was completely reabsorbed, no chest drains were inserted and the patient was transferred to our toxicological intensive care unit. Recurring drug-induced psychosis had to be treated with repeated doses of haloperidol. The emphysema was slowly reabsorbed without any further complication. The patient was transferred back to a psychiatric ward after five days. CONCLUSION: Although cannabis is thought to be one of the "safe" drugs, its abuse can have life-threatening effects. One complication is the occurrence of a pneumothorax after a Valsalva maneuver. As the rate of cannabis abuse has been increasing during the last few years, the risk of life-threatening complications should be mentioned in relevant publications and as part of drug education. Patients presenting with dyspnea should always be carefully questioned about possible drug abuse.

A frightening complication of general anaesthesia for paediatric dental extractions.

We report a case of eight year old child who developed severe subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum and pneumoperitonium in recovery room after apparently uneventful general anaesthesia for eight primary teeth extractions. Causes and treatment of these complications are discussed.

A rare complication of chlorine gas inhalation: pneumomediastinum.

Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tract.

Extensive pneumothorax, pneumomediastinum and surgical emphysema as a complication of bleomycin therapy.

Bleomycin is a commonly used chemotherapeutic agent and one of the commonest cytotoxic drugs leading to pulmonary parenchymal damage. It generally leads to interstitial pneumonitis and fibrosis, hypersensitivity reactions and acute respiratory distress syndrome. We describe an 8-year-old boy who, following prolonged bleomycin therapy, demonstrated extensive air dissection and extrapulmonary air, an unusual and fatal complication.