Pneumomediastinum, pneumorachis, subcutaneous emphysema: An unusual complication of leukemia in a child

Pneumorrhachis(PR), or epidural emphysema, denotes the presence of air in the spinal epidural space. It can be associated with a variety of etiologies, including trauma; recent iatrogenic manipulations during surgical, anesthesiological and diagnostic interventions;malignancy and its associated therapy. It usually represents an asymptomatic epiphenomenon but also can be symptomatic by itself, as well as by its underlying pathology, and rarely can be fatal. The pathogenesis and etiology of PR are varied and can sometimes be a diagnostic challenge. As such, there are no standard guidelines for the management of symptomatic PR and its treatment is often individualized. Here, we present a case of a 14-year-old boy treated for leukemia who developed this complication and whether chemotherapy related or not, it proved to be fatal for him. To our knowledge, this is the first case in the literature of this complication with acute lymphoblastic leukemia.

Pneumomediastinum after acute lymphoblastic leukemia and chemotherapy?

Pneumomediastinum,pneumorachis and subcutaneous emphysema are frequently benign and most commonly result from air escaping from the upper respiratory tract,intrathoracic airways,or gastrointestinal tract.Gas can also be generated by certain infections or reach the mediastinal space from outside air after trauma or surgery.In the article presented by Showkat et al a 14-year-old male patient with acute lymphoblastic leukemia(ALL) under chemotherapy developed pneumomediastinum,pneumorachis and subcutaneous emphysema.In the author's opinion,these complications were caused by ALL or chemotherapy that progressed to severe respiratory failure until the patient finally died in the intensive care unit.I would like to underline some important points,which have been raised following a paper published in the October issue of World Journal of Clinical Cases.

Prevention and Management of Related Complication due to Laparoscopic Operation：Pneumothorax，Pneumomediastinum And Subcutaneo

Essential prerequisite of laparoscopic operation is establishing and maintaining pneumoperitoneum with a certain pressure. But under certain circumstances CO2-gas insuffiating could induce pneumothorax , pneumomediastinum and subcutaneous emphysema during the operation. to probe the mechanism of the above complications. 2 typical cases were reported with attempt to probe the mechanism of the development of such applications. We believe that high intraabdominal pressure during operation is the primary cause of the complications. The essentials of prevention and management of such complications were proposed.

Spontaneous pneumomediastinum in an elderly COVID-19 patient:A case report

BACKGROUND Spontaneous pneumomediastinum(SPM)is more common in young adults,usually caused by external factors like trauma.It causes symptoms such as chest pain or dyspnea,but it is rare to see elderly patients who develop SPM.Here we report the case of an elderly patient diagnosed with coronavirus disease 2019(COVID-19)who neither got mechanical ventilation nor had chest trauma but were found to develop SPM for unknown reason.CASE SUMMARY A 62-year-old man complained of a 14-d history of fever accompanied by dry cough,shortness of breath,wheezing,myalgia,nausea,and vomiting.Real-time fluorescence polymerase chain reaction confirmed the diagnosis of COVID-19.The patient was treated with supplementary oxygen by nasal cannula and gamma globulin.Other symptomatic treatments included antibacterial and antiviral treatments.On day 4 of hospitalization,he reported sudden onset of dyspnea.On day 6,he was somnolent.On day 12,the patient reported worsening right-sided chest pain which eventually progressed to bilateral chest pain.He was diagnosed with SPM,with no clear trigger found.Conservative treatment was administrated.During follow-up,the pneumomediastinum had resolved and the patient recovered without other complications.CONCLUSION We presume that aging lung changes and bronchopulmonary infection play an important part in the onset of SPM in COVID-19,but severe acute respiratory syndrome may represent a separate pathophysiologic mechanism forpneumomediastinum.Although the incidence of SPM in elderly patients is low,clinicians should be alert to the possibility of SPM in those infected with severe acute respiratory syndrome coronavirus 2 for life-threatening complications such as cardiorespiratory arrest may occur.

Usefulness of Chest Computed Tomography for Diagnosis of Idiopathic Pneumomediastinum with Negative Findings on Plain X-Ray

Idiopathic pneumomediastinum is rare in children. Few cases of patients with pneumomediastinum show negative findings on X-ray examination. Chest computed tomography (CT) was very useful for the diagnosis and evaluation of the extent of pneumomediastinum. We report here a case of idiopathic pneumomediastinum in a 15-year-old boy who exhibited no significant chest X-ray finding. The patient was referred to our institute for the further evaluation of pre-cordial pain and breathing difficulty. Precordial pain suddenly developed, when he was carrying a portable shrine on his shoulder (day of onset). He was admitted to another institute 3 days after onset because of worsening precordial pain. On admission, he presented with 98% saturation of hemoglobin in the peripheral blood under room air. Plain chest X-ray also revealed no abnormal findings. A half-dissolved gastrographin swallow showed no leakage of gastrographin from the pharynx and esophagus to the mediastinum, and no diverticulum within the esophagus. Plain chest CT revealed extensive emphysema around the trachea from the neck to the portion inferior to the carina of trachea. The patient was diagnosed with idiopathic pneumomediastinum because the cause was unclear. We decided to admit him to our institute under fasting conditions and rest. His symptoms improved 3 days after onset. The lesion had disap-peared 8 days after onset on chest CT. When young people experience precordial pain which increases on inspiration, we must consider pneumomediastinum in a differential diagnosis, and it is important to perform chest CT.

Spontaneous neonatal pneumomediastinum

Radiolucency in the superior mediastinum may be caused by a congenital cystic mass or pneumomediastinum. Most cases of pneumomediastinum occur in preterm newborns with surfactant deficiency receiving treatment with positive pressure ventilation. Spontaneous pneumomediastinum in term neonates is also rarely reported. We report the outcome for a term neonate with respiratory distress who was transferred for surgical evaluation of a cystic superior mediastinal mass.

Pneumomediastinum： Unusual Complication ofInfection with Influenza A HIN1 （About a Case）

Influenza A （H IN l） is a viral infection which can be responsible of severe lung diseases. Mediastinal symptoms are rareespecially pneumomediastinum.The aim of this work is to report a case of a young immunocompromised patient who was admitted tothe intensive care unit for acute respiratory distress that revealed Influenza A H1NI pulmonary infection withpneumomediastinum .The evolution was favorable.

Pneumomediastinum after Orthognathic Surgery: Case Report and Review of the Literature

Orthognathic surgery in general addresses young patients and aims to improve their bite function and to harmonize their facial aesthetics. Secure surgical standards and a defined post-surgical protocol of after-care are indispensable to reduce surgical as well as anaesthesiological risks in this area of complex elective surgery. The development of pneumomediastinum is a rare incident but threatens the patients’ physical integrity. The case of a young healthy male who underwent Le Fort I osteotomy in combination with bilateral mandibular sagittal split osteotomy and postoperatively developed pneumomediastinum is presented, together with a discussion of the possible reasons for this rare complication of orthognathic surgery. The avoidance of life-threatening coincidences must be one main focus in the preparation and aftercare in elective orthognathic surgery.

Cervicofacial Emphysema and Pneumomediastinum Complicating a Dental Extraction

Background: Pneumomediastinum and subcutaneous emphysema are a rare and well-known complication of dental procedures. Many cases go unrecognized and resolve spontaneously, while others may require specific therapeutic management to prevent complications. Case Presentations: We report a case of cervical subcutaneous emphysema and pneumomediasitnum occurring after extraction of lower right second molar. The emphysema was detected 2 hours after dental surgery. This paper reports on the diagnosis and treatment of subcutaneous emphysema and pneumomediastinum. Conclusion: In order to prevent this complication, air turbine high speed drills should be used only in necessary cases.

Clinical Approach for the Pneumomediastinum after Blunt Chest Trauma

Objective: Pneumomediastinum (PM) can be observed after blunt and penetrating chest trauma. Most of the patients with PM due to trauma can be managed conservatively. This study aimed to evaluate the cases with PM on thorax computed tomography (CT) after blunt chest trauma (BCT). Methods: Medical records of patients with PM due to BCT between January 2000 and December 2014 were reviewed retrospectively. Thorax CT was used to verify pneumomediastinum in all patients. Twenty-four patients which had different causes of PM (penetrating trauma, iatrogenic, spontaneous) were excluded from the study. Data of sixty-nine patients with the diagnosis of PM secondary to BCT and who were observed without any further procedure for the cause of PM, were evaluated retrospectively. Results: There were 59 male and 10 female patients with the mean age of 47.60 ± 17.47 years (range, 16 to 80 years). The most common cause of PM etiology was traffic accident with a rate of 38 (55.06%) patients, followed by fall from height in 25 (36.24%), compression in 3 (4.35%) and drubbing in 3 (4.35%) patients. There was a 12.46 ± 6.42 days (range, 6 to 28 days) mean duration of chest tube drainage which was performed for accompanying pathologies like pneumothorax and hemothorax. No complication was determined for short and long term follow-up of patients when all hospital records were analyzed in terms of complication. Conclusions: PM after BCT may be a marker of esophageal and tracheobronchial injury and invasive procedures like bronchoscopy and endoscopy can be needed for differential diagnosis. We evaluated 69 patients in good general status and no need for intensive care management with PM in this study and observed them without any further procedure. As a result of these findings we concluded that for the PM patients after BCT with uneventful clinical course, conservative treatment without any further procedure is a safe and sufficient method.

The Role of Oropharyngeal Barotrauma as a Cause of Pneumomediastinum: Report of a Case

Free air or gas in mediastinum is defined as pneumomediastinum. This is a rare condition which orginates from over distention of alveolus and alveolar rupture by barotrauma. A 6-year-old boy was admitted to our department with sudden onset, swelling of neck and face that developed during drinking water from tap by using his mouth. Physical examination revealed the presence of subcutaneous emphysema over the two side of the face that extended toward the neck bilaterally. The chest X-ray and CT of the thorax, when performed, revealed the diagnosis of pneumomediastinum and extrathoracic subcutaneous emphysema. Interestingly neither trachea-bronchial nor esophageal pathology was found by emergent rigid bronchoscopy and endoscopy for etiology of pneumomediastinum. Antibiotic treatment and oxygen therapy were given to the patient with chest pain and dyspnea. During the following days, the patient’s condition improved notably, with almost total resolution of the cervical emphysema and pneumomediastinum confirmed by daily chest X-ray and control thorax CT. He was discharged home after 6 days. The emphysema gradually resolved. Pneumomediastinum caused by barotrauma is a rare condition and only conservative treatment is required when the other causes are ruled out.

Covid-19 pneumonia:Timing of pneumomediastinum and pneumothorax in 11 patients

Purpose:As the pandemic continues,many complications,previously recognized as rare,are now being reported as more than frequent complications of Covid-19 pneumonia.Of those,pneumomediastinum and pneumothorax are gaining attention.Their mechanism of occurrence/trigger is not fully understood,but the timing at which they occur is unclear.Methods:This is a case series of 11 Covid-19 patients with pneumomediastinum;retrospectively,we shed light on some of the patients’characteristics,the role of mechanical ventilation,and the timing of pneumomediastinum after initiation of mechanical ventilation.Results:We found that despite following the lung-protective strategy and despite keeping a plateau pressure at an acceptable range,most of our patients had an acute event around the same timing of mechanical ventilation.Conclusions:The similar timing raises questions about other risk factors that remain unknown.Timing and steroids can contribute to the higher incidence of these complications.

Subcutaneous cervical emphysema and pneumomediastinum due to a lower gastrointestinal tract perforation

This case report describes a 69-year-old man presen-ting with an extensive subcutaneous emphysema in his neck and generalized peritonitis caused by a lower gastrointestinal tract perforation. This case emphasizes that subcutaneous emphysema patients with negative thoracic findings should be scrutinized for signs of retroperitoneal hollow viscus perforation.

Spontaneous pneumomediastinum and Macklin effect:Overview and appearance on computed tomography

Spontaneous pneumomediastinum(SPM) is described as free air or gas located within the mediastinum that is not associated with any noticeable cause such as chest trauma.SPM has been associated with many conditions and triggers,including bronchial asthma,diabetic ketoacidosis,forceful straining during exercise,inhalation of drugs,as well as other activities associated with the Valsalva maneuver.The Macklin effect appears on thoracic computed tomography(CT) as linear collections of air contiguous to the bronchovascular sheaths.With the recent availability of multidetector-row CT,the Macklin effect has been seen in the clinical setting more frequently than expected.The aim of this review article is to describe the CT imaging spectrum of the Macklin effect in patients with SPM,focusing on the common appearance of the Macklin effect,pneumorrhachis,and persistent SPM with pneumatocele.

Pneumocystis jiroveci pneumonia and pneumomediastinum in an anti-TNFαnaive patient with ulcerative colitis

We report the case of a 21-year-old man who was noted to have pneumomedi astinum during an admission for an acute flare of ulcerative colitis.At that time,he was on maintenance treatment with azathioprine at a dose of 1.25 mg/kg per day,and had not received supplementary steroids for 9 mo. He had never received anti-tumor necrosis factor (TNF)αtherapy.Shortly after apparently effective treatment with intravenous steroids and an increased dose of azathioprine,he developed worsening colitic and new respiratory symptoms,and was diagnosed with Pneumocystis jiroveci(carinii)pneumonia(PCP). Pneumomediastinum is rare in immunocompetent hosts,but is a recognized complication of PCP in human immunodeficiency virus(HIV)patients, although our patient’s HIV test was negative. Treatment of PCP with co-trimoxazole resulted in resolution of both respiratory and gastrointestinal symptoms,without the need to increase the steroid dose.There is increasing vigilance for opportunistic infections in patients with inflammatory bowel disease following the advent of anti-TNFαtherapy. This case emphasizes the importance of considering the possibility of such infections in all patients with inflammatory bowel disease,irrespective of the immunosuppressants they receive,and highlights the potential of steroid-responsive opportunistic infections to mimic worsening colitic symptoms in patients with ulcerative colitis.

Successful treatment of rapidly progressive interstitial lung disease complicated by a refractory pneumomediastinum in a patient with anti-MDA5 antibody-positive dermatomyositis

Introduction:Anti-melanoma differentiation-associated gene 5-positive dermatomyositis(anti-MDA5+DM)is a distinct subtype of DM,which is characterized by typical cutaneous features,minimal or no muscle involvement and notable interstitial lung disease,which typically progresses rapidly and has a high mortality.Spontaneous pneumomediastinum(PNM),a relatively unusual but serious complication of anti-MDA5+DM,further increases mortality.Currently,there is no generally accepted treatment regimen for anti-MDA5+DM-associated PNM.Case Description:A 53-year-old man with anti-MDA5+DM presented with rapidly progressive interstitial lung disease that progressed to diffuse subcutaneous emphysema and PNM despite aggressive immunosuppressive therapies.He responded well to combined anti-infection treatments,moderate immunotherapy,and continuous oxygen therapy.Conclusion:Comprehensive screening for potential infections,as well as close monitoring of the patient's immune status is essential for individualizing treatment and maximizing prognosis.

Mediastinal emphysema in the context of perforated gastric ulcer

In the context of mediastinal emphysema/pneumomediastinum,the main aetiologies are associated with oesophageal perforation,lung pathology or post head and neck surgery related.The main way to differentiate the pathologies would be through Computed Tomographic Imaging of the Thorax and abdomen with oral and intravenous contrast in the context of triple phase imaging.The causes of pneumomediastinum should be differentiated between traumatic and non-traumatic.Oesophageal perforation(Boerhaave syndrome)is associated with Mackler’s triad in upto 50%of patients(severe retrosternal chest pain,pneumomediastinum,mediastinitis).Whereas in cases of lung pathology this can be associated with pneumothorax and pleural effusion.

Pneumomediastinum Secondary to Foreign Body Aspiration： Clinical Features and Treatment Explorement in 39 Pediatric Patients

Background：Pneumomediastinum （PM） secondary to foreign body aspiration （FBA） is rare in children.Although it is mainly benign,some cases may be fatal.Due to the rare nature of this clinical entity,proper assessment and management have been poorly studied so far.Here,we characterized the presentation and management of this clinical entity and provided an evaluation system for the management.Methods：We retrospectively reviewed children with PM secondary to FBA,who were treated in Beijing Children＇s Hospital from January 2010 to December 2015.All patients were stratified according to the degree of dyspnea on admission,and interventions were given accordingly.Bronchoscopic removals of airway foreign bodies （FBs） were performed on all patients.For patients in acute respiratory distress,emergent air evacuation and/or resuscitations were performed first.Admission data,interventions,and clinical outcomes were recorded.Results：A total of 39 patients were included in this study.The clinical severity was divided into three grades （Grades Ⅰ,Ⅱ,and Ⅲ） according to the degree of dyspnea.Thirty-one patients were in Grade Ⅰ dyspnea,and they simply underwent bronchoscopic FBs removals.PM resolved spontaneously and all patients recovered uneventfully.Six patients were in Grade Ⅱ dyspnea,and emergent drainage preceded rigid bronchoscopy.They all recovered uneventfully under close observation.Two exhausted patients were in Grade Ⅲ dyspnea.They died from large PM and bilateral pneumothorax,respectively,despite of aggressive interventions in our hospital.Conclusions：PM secondary to FBA could be life-threatening in some patients.The degree of dyspnea should be evaluated immediately,and patients in different dyspnea should be treated accordingly.For patients in Grade Ⅰ dyspnea,simple bronchoscopic FBs removals could promise a good outcome.For patients in Grade Ⅱ dyspnea,emergent air evacuation and/or resuscitation should precede a bronchoscopy before the children become exhausted.

Trauma-induced“Macklin effect”with pneumothorax and large pneumomediastinum,disguised by allergy

A 56-year-old man presented spontaneously to the Emergency Department complaining of facial and neck oedema after assumption of nonsteroidal anti-inflammatory drugs(NSAIDS).The triage nurse assigned the patient to Accident&Emergency(A&E)doctor as probable allergic reaction to NSAIDS.Chest X-ray(CXR),ordered after 24 hours,revealed a huge subcutaneous chest and neck emphysema without clearly visible pneumothorax.Subsequent chest CT scan showed a small left pneumothorax and a large amount of air in the mediastinum.The patient was conservatively treated since he was eupnoeic and hemodynamically stable.The pathophysiology of pneumomediastinum was first described by Macklin in 1939.The Macklin effect involves alveolar ruptures with air dissection along bronchovascular sheaths to the mediastinum.In this case the patient did not report in his history a recent blunt thoracic trauma and the initial suspicion of an allergic reaction has prevented physicians to immediately achieve the correct diagnosis.

Stevens-Johnson Syndrome complicated by obstructive uropathy,pneumothorax,and pneumomediastinum:a case report and literature review

Background:Stevens-Johnson Syndrome(SJS)is an acute mucocutaneous eruption with blisters of the skin and haemorrhagic erosions of mucous membranes.This report describes air-leak syndrome and obstructive uropathy occurring simultaneously in a teenage patient affected by SJS.Case presentation:A 17-year-old Malay female with SJS suffered from bilateral pneumothoraces,pneumomediastinum,and obstructive uropathy as early complications of her disease.She required intubation,chest tube insertion,and bilateral ureteric stenting as part of her intensive care management.These extracutaneous complications of renal and pulmonary systems were likely secondary to widespread epithelial detachment.Conclusion:Despite paucity of cases in adult literature,post-renal causes for acute kidney injury must be considered in SJS,especially in the setting of gross haematuria.Bedside point-of-care ultrasonography may be a useful tool for excluding obstructive uropathy.Pneumothorax is a rare but documented complication of SJS in paediatric cases and,to a lesser extent,adult patients.Extra care should be exercised when caring for mechanically ventilated patients suffering from SJS.