Spontaneous Pneumomediastinum: A Diagnostic Challenge in a Patient Presenting With Excessive Vomiting and Neck Swelling.

Hamman's syndrome, or spontaneous pneumomediastinum, refers to free air in the mediastinum without an apparent cause and typically affects young people. This case report describes a 33-year-old man who presented with neck swelling following excessive vomiting due to alcohol consumption. Clinical examination revealed subcutaneous emphysema of the neck, and imaging confirmed pneumomediastinum. Initial suspicion of Boerhaave syndrome led to aggressive supportive management, but further imaging ruled out oesophageal perforation, confirming Hamman's syndrome. The patient was treated conservatively and discharged after a successful trial of a light diet. This case highlights the diagnostic challenges of Hamman's syndrome, given that its symptoms overlap with more serious conditions like Boerhaave syndrome. Prompt recognition and appropriate conservative management are essential for favourable outcomes, emphasizing the benign and self-limiting nature of Hamman's syndrome.

Right pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema as rare complications after ERCP: a case report.

Endoscopic retrograde cholangiopancreatography is a complex procedure with a significant risk of severe consequences. We herein report a 56-year-old Middle Eastern female who was diagnosed with acute ascending cholangitis. Endoscopic retrograde cholangiopancreatography was performed with gallstone absorption and stent implanting. However, the patient developed significant pneumothorax; pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema of the abdomen, chest, right arm and shoulder, face and right orbital area. Radiological studies demonstrated no evidence of perforation on bowel obstruction. The patient was treated successfully with good results and post-operative follow-up was unremarkable. In conclusion, air leakage following endoscopic retrograde cholangiopancreatography without evidence of perforation is extremely rare. While pneumothorax development usually requires thoracostomy; pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema are usually treated conservatively.

Extracorporeal membrane oxygenation for prevention of barotrauma in patients with respiratory failure: A scoping review.

BACKGROUND: Barotrauma is a frequent complication in patients with severe respiratory failure and is associated with poor outcomes. Extracorporeal membrane oxygenation (ECMO) implantation allows to introduce lung-protective ventilation strategies that limit barotrauma development or progression, but available data are scarce. We performed a scoping review to summarize current knowledge on this therapeutic approach. METHODS: We systematically searched PubMed/MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies investigating ECMO as a strategy to prevent/limit barotrauma progression in patients with respiratory failure. Pediatric studies, studies on perioperative implantation of ECMO, and studies not reporting original data were excluded. The primary outcome was the rate of barotrauma development/progression. RESULTS: We identified 21 manuscripts presenting data on a total of 45 ECMO patients. All patients underwent veno-venous ECMO. Of these, 21 (46.7%) received ECMO before invasive mechanical ventilation. In most cases, ECMO implantation allowed to modify the respiratory support strategy (e.g., introduction of ultraprotective/low pressure ventilation in 12 patients, extubation while on ECMO in one case, and avoidance of invasive ventilation in 15 cases). Barotrauma development/progression occurred in <10% of patients. Overall mortality was 8/45 (17.8%). CONCLUSION: ECMO implantation to prevent barotrauma development/progression is a feasible strategy and may be a promising support option.

Pneumomediastinum.

Pneumomediastinum, air within the mediastinum, is the manifestation of a variety of causes including those that are benign and some resulting in severe morbidity and even mortality. This article reviews the epidemiology, etiology, and pathophysiology of pneumomediastinum as an independent pathologic and physiologic entity, as well as reviews the workup and management of those patients who are diagnosed with pneumomediastinum.

A rare case of subcutaneous emphysema in a young and healthy patient with parainfluenza virus 3 pneumonia.

An 18-year-old healthy male complained of a 7-day history of fever, cough, and sore throat, along with a three-day history of left facial swelling. The x-rays revealed subcutaneous emphysema in the chest, neck, face, and mediastinum region (Pneumomediastinum). Furthermore, an area of infiltration was visible, indicating pneumonia. Therefore, we immediately started him on intravenous antibiotics. We then moved the patient to an isolation room, considering pulmonary tuberculosis as one of the differential diagnoses. However, the Acid Fast Bacilli (AFB), Mycobacterium Tuberculosis Bacteria-Polymerase Chain Reaction (MTB PCR), and sputum for gram stain and culture were all negative. On the other hand, the test for parainfluenza virus 3 was positive. The patient was observed with a daily chest x-ray to monitor the progress of pneumonia and subcutaneous emphysema. Fortunately, the subcutaneous emphysema was significantly reduced on a daily basis until it was completely resolved before discharge home.

Spontaneous pneumomediastinum: A comprehensive review of diagnosis and management.

Pneumomediastinum is a rare condition defined by the presence of air in the mediastinum. In the absence of traumatic injury, iatrogenic injury, or clear etiology, it is called spontaneous pneumomediastinum (SPM). Spontaneous pneumomediastinum most commonly occurs in younger individuals and has a self-limiting course with a good outcome. The purpose of the present manuscript is to systematically review the existing literature on SPM evaluation and management for updated clinical understanding of this condition. A literature search was conducted of publications about SPM on MEDLINE/PubMed and Google Scholar by identifying all the articles with key search terms "pneumomediastinum" and "spontaneous pneumomediastinum". Inclusion criteria were case series published in English between 1980 and 2023. In total, 24 case series were selected and reviewed to determine presenting symptoms, clinical signs and predisposing factors associated with spontaneous pneumomediastinum. Most patients were male; the average age at diagnosis was 26.3 years. The most common presenting symptoms were chest pain and dyspnea. The most common exam finding was subcutaneous emphysema, in 35.4% of patients. Only 5.9% had the classic Hamman's sign. Risk factors include history of asthma, history of smoking, and recent physical activity. This manuscript presents an extensive review of relevant literature highlighting the diagnosis and essential management of spontaneous pneumomediastinum.

Spontaneous Pneumomediastinum in a Patient With Undiagnosed Ankylosing Spondylitis.

Spontaneous pneumomediastinum (SPM) is an uncommon condition characterized by air in the interstices of the mediastinum. Management generally involves supportive care; however, if a patient inspires high concentrations of oxygen, the mediastinal air will be absorbed faster. A 23-year-old man who presented with acute-onset breathlessness with a history of more than a year of lower backache was diagnosed with SPM and accompanying ankylosing spondylitis (AS) by a chest CT and spinal MRI and was treated conservatively. This case is being reported for its uniqueness, as SPM with underlying AS is rare.

The Macklin Effect: An Underestimated Cause of Pneumomediastinum.

The Macklin effect is a rare but potentially serious complication of pneumomediastinum, caused by the dissemination of air from the lungs into the subcutaneous tissue and mediastinum after severe chest trauma or invasive manipulation. Early recognition is crucial for proper management of the patient. A 33-year-old male skidded while riding a motorcycle, lost control of the vehicle, and crashed into a utility pole with a thoracic contusion. He was admitted to the hospital; a computed tomography (CT) of the chest and abdomen was requested, which ruled out the presence of fractures and showed air in the mediastinum and subcutaneous cellular tissue, with features suggestive of the Macklin phenomenon. After 72 hours of inpatient monitoring, the patient was discharged to the general surgery outpatient clinic. The Macklin phenomenon occurs as a result of airway rupture due to negative pressure caused by trauma or invasive mechanical ventilation. Risk factors include a higher prevalence in young males, a slender stature and above-average height, and an age range of 12 to 35 years. Early detection of the Macklin phenomenon is crucial to recognize and prevent further complications. This case demonstrated the importance of considering the Macklin effect as a cause of pneumomediastinum in patients with severe chest trauma. Diagnostic imaging plays a key role in confirming the diagnosis and planning treatment.

Ischaemic Strokes Caused by Spontaneous Cerebral Air Embolism, A Rare Complication of Interstitial Lung Disease.

Air embolism is a rare cause of ischaemic stroke. It is known that air can enter the cerebral arterial circulation from pulmonary venous circulation through a bronchovenous fistula, or in cases of pulmonary barotrauma in deep-sea diving. We describe a case of spontaneous cerebral air embolism against a background of advanced interstitial lung disease (ILD). To our knowledge, this case demonstrates a mechanism of stroke in ILD patients that has not been previously described. LEARNING POINTS: This case demonstrates a mechanism of stroke in patients with severe interstitial lung disease (ILD) that has not been previously described, and we suggest that in cases of advanced ILD, clinicians should consider this as a possible mechanism of stroke. The management of these patients should include transferring them to hyperbaric facilities to prevent further air emboli.

Drug-Induced Acute Eosinophilic Pneumonia With Pneumomediastinum: An Unusual Presentation.

A 27-year-old female, with no significant past medical history, presented to the casualty department with a two-week history of progressive dyspnea, cough, and fever. She reported that she had recently started taking a non-conventional alternative medication for her irregular menstrual cycles. Chest radiography demonstrated bilateral alveolar opacities, and computed tomography (CT) of the chest revealed bilateral ground-glass opacities and pneumomediastinum. Laboratory testing showed peripheral blood eosinophilia, and bronchoscopy with bronchoalveolar lavage confirmed an elevated eosinophil count. Based on the clinical presentation, radiographic and laboratory findings, and exclusion of other etiologies, a diagnosis of drug-induced eosinophilic lung disease with pneumomediastinum was made. The alternative non-conventional drug was immediately discontinued and the patient was treated with systemic corticosteroids, leading to a rapid improvement in her symptoms and radiographic abnormalities. A repeat CT of the chest after 15 days revealed significant resolution of the ground-glass opacities and complete resolution of pneumomediastinum. This case highlights the importance of thorough medication history and vigilance for potential adverse effects of non-conventional treatments.

Anti-melanoma Differentiation-Associated Gene 5 (Anti-MDA5) Dermatomyositis-Associated Interstitial Lung Disease Complicated by Pneumomediastinum: A Case Report and Literature Review.

Anti-melanoma differentiation-associated gene 5 (anti-MDA5) dermatomyositis (DM) is a subset of amyopathic myositis and is associated with unique cutaneous manifestations and rapidly progressive interstitial lung disease (RP-ILD). A rare complication associated with high mortality is the occurrence of pneumomediastinum. We present a case of a 58-year-old female with anti-MDA5 DM-associated interstitial lung disease (ILD) complicated by pneumomediastinum. Treatment with pulse dose steroids and intravenous cyclophosphamide led to clinical improvement and resolution of the pneumomediastinum. Our case emphasizes the recognition of ILD-associated pneumomediastinum in patients with anti-MDA5 DM. Swift diagnosis and aggressive treatment are crucial due to the associated high mortality.

The pathologies of migrants who travel by boat documented on imaging.

The migration phenomenon is increasingly common worldwide. It is essential for radiologists to be aware of the endemic diseases of the migrant's country as well as the characteristics of the journey to be able to understand and interpret radiological findings when admitted to our centre. This article aims to use imaging from our centre to describe the most common pathologies that migrant patients present with after long journeys by boat.

Pneumomediastinum and pneumoretroperitoneum after COVID-19: concealed intestinal perforation.

BACKGROUND: With the prevalence of coronavirus disease 2019 (COVID-19), many severe cases have been discovered worldwide. Here, a case of concurrent pneumomediastinum, pneumoretroperitoneum, and intestinal perforation was reported. This case was the first report on COVID-19-induced related complications. CASE PRESENTATION: A 74-year-old female patient was hospitalized for COVID-19. Air leakage was unexpectedly found during imaging reexamination. Considering the unobvious subjective feeling of the patient, a conservative treatment was given at the early stage, and finally, sigmoid colon perforation was surgically confirmed. The family gave up the treatment at last, because the patient could not be taken off the ventilator. Coincidentally, the patient also had abnormal renal anatomical position. This situation led to an abnormal air leakage direction and the atypical manifestations of peritonitis. It was also one of the important reasons for the delayed diagnosis and treatment of the disease. CONCLUSIONS: Clinicians should be vigilant for spontaneous gastrointestinal perforation in patients with COVID-19, particularly those undergoing treatment with glucocorticoids and tocilizumab. The case is shared to highlight this rare and fatal extrapulmonary manifestation of COVID-19 and further assist clinicians to raise their awareness and timely implement imaging investigation and multidisciplinary intervention so as to facilitate early discovery, diagnosis and treatment and reduce the mortality.

Spontaneously Resolving Pneumoperitoneum and Pneumomediastinum: A Report of Two Cases.

We present here an interesting case report of two patients with spontaneous pneumomediastinum and iatrogenic pneumoperitoneum. The patients were assessed and queried following a chest X-ray abnormality and query based on the history of recent urological procedures on a background of awaiting gastro-oesophageal surgery at a tertiary centre respectively. Although these patients were successfully managed with the best supportive approach and periodic imaging review, it remains important to be aware that fatalities have been reported in the literature. We hope this case report will help those involved in the care of the patient to be aware of these conditions as differentials when history points towards episodes of coughing or recent surgical input.

Hamman's Syndrome after Vaginal Delivery: A Case of Postpartum Spontaneous Pneumomediastinum with Subcutaneous Emphysema and Review of the Literature.

Hamman's syndrome is a rare condition that mostly affects young males, often with a predisposition to asthma. It includes the presence of free air in the mediastinum and subcutaneous emphysema with no other underlying cause such as trauma, infection, or administration of any sort of mask support with hyperpressure. It occurs spontaneously and often in association with a prolonged Valsalva maneuver. This might explain why there are some cases of Hamman's syndrome among young females giving birth. Here, we present a case report of a 24-year-old non-smoker primigravida with Hamman's syndrome. She presented with symptoms a few hours after an uncomplicated vaginal delivery at 40 + 1 weeks of pregnancy where the active phase of labor lasted for three hours with normal progress. The second stage lasted for 30 min, with no signs of distress on CTG. The symptoms (pain in the right ear, swelling and pain in the neck, chest tightness, shortness of breath, dysphagia, odynophagia, and pain in the upper thorax on the right side) and objective findings as subcutaneous crepitations in the neck, parasternal region, right axillary fossa, clavicle and over the chest resolved spontaneously after a few days of observation and conservative management. We also give a systemic review of reported cases since 2000 to provide an overview of the pathomechanism, symptoms, diagnostics, treatment, and management of this condition. Hamman's syndrome is a rare, usually benign, but potentially serious complication that can occur during the second stage of labor. Diagnostics include inquiring about typical symptoms, clinical examination, and chest x-ray or CT scan. Treatment is usually conservative with oxygen, bronchodilators, and pain relief. The recurrence rate is low and there is no contraindication to vaginal delivery in future pregnancies. However, it is suggested that physicians and midwives be cautious and consider a low threshold for instrumental delivery or cesarean section to avoid excessive Valsalva maneuvers.

Laryngotracheal trauma-induced Macklin effect: A case report.

Laryngotracheal trauma is a relatively rare traumatic injury seen particularly in young male adults. Trauma due to strangulation is one of its most frequent circumstances. However rare, pneumomediastinum is a particular complication of severe blunt neck injuries leading to alveolar ruptures. This phenomenon, described as the Macklin effect, requires early diagnosis, and its management varies from conservative to surgical treatment depending on the severity of symptoms. Our aim is to describe the case of a 21-year-old male who presented with blunt neck trauma. Clinical and imaging findings revealed subcutaneous neck emphysema and pneumomediastinum. Treatment was conservative leading to complete resolution of the injuries and the patient was discharged after 2 weeks.

Patient self-inflicted lung injury associated pneumothorax/pneumomediastinum is a risk factor for worse outcomes of severe COVID-19: a case-control study.

We aimed to determine the clinical characteristics of patient self-inflicted lung injury (P-SILI)-associated pneumothorax/pneumomediastinum, to reveal its risk factors, and to assess its impact on severe COVID-19 cases. In total, 229 patients were included in this case-control study. They were randomly divided into either the case group or the control group as per the inclusion and exclusion criteria. The two groups were further analyzed to reveal the risk factors of spontaneous pneumothorax/pneumomediastinum (SP/P). Finally, risk factors for death were analyzed in the case group and the relationship between death and SP/P was also analyzed among all patients. The mean age of patients was 59.69 ± 17.01 years, most of them were male (74.2%), and 62.0% of them had comorbidities upon admission. A respiratory rate higher than 30 BPM was a risk factor for SP/P (OR 7.186, 95% CI 2.414-21.391, P < 0.001). Patients with delayed intubation due to early application of HFNC or NIV had a higher mortality rate when they developed SP/P (P < 0.05). Additionally, advanced age increased the risk of death (P < 0.05). Finally, SP/P may be a risk factor for death among patients with severe COVID-19 (OR 2.047). P-SILI occurs in severe COVID-19 with acute respiratory failure. It is necessary to identify the risk factors of P-SILI, the indicators of severe P-SILI, and the preventive measures.

Thoracic endometrial syndrome with unilateral exudative pleural effusion.

A woman in her 40s presented with exertional dyspnoea with an absence of haemoptysis, cough, fever and weight loss. The patient had a medical history of extensive endometriosis. Investigations revealed a large right-sided pleural effusion. The effusion was aspirated and was exudative in nature.A contrast-enhanced CT thorax was performed to help exclude dual pathology. The only positive finding was bilateral breast nodules, subsequently found to be benign fibroadenomas on histological analysis of biopsy samples.After malignancy was ruled out as a cause, the patient was referred for medical thoracoscopy for a biopsy and other investigations. Histology demonstrated the presence of endometrial tissue in the pleura and thereby confirmed the diagnosis of thoracic endometrial syndrome.Video-assisted thoracoscopic surgery repair of diaphragm and talc pleurodesis was carried out in an uncomplicated procedure and the patient was discharged with good recovery.

Spontaneous Pneumomediastinum Induced by a Combination of Flu-A Infection and E-cigarettes: A Case Report.

Pneumomediastinum (PM) and subcutaneous emphysema are characterized by extra-alveolar air within the mediastinum and subcutaneous tissue. PM may occur spontaneously or due to trauma or an underlying airway disease. Spontaneous pneumomediastinum (SPM) may be caused by intractable vomiting, forceful coughing, child birthing, or performing a Valsalva maneuver. However, there are limited studies or case reports that present a combination of influenza A infection and electronic cigarette (e-cigarette)-induced SPM. This case report presents SPM in a previously healthy 20-year-old female with untreated influenza A infection and a history of e-cigarette use who presented to the emergency department with fever, cough, chest pain, dyspnea, and vomiting. Her physical examination was significant for neck tenderness, subcutaneous neck crepitus, and increased respiratory effort. Diagnostic evaluation included a chest X-ray and chest computed tomography that revealed PM with subcutaneous emphysema extending into the neck, as well as a negative Gastrografin study. She was treated conservatively and discharged after two days, with a follow-up scheduled at a pulmonary clinic. This case report highlights the need for a detailed substance use history, particularly e-cigarette use, when determining the etiology of SPM in a previously healthy patient. Management for SPM is conservative and should include addressing underlying etiologies with special attention to cessation and education of e-cigarettes and illicit substances.