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CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 95-97

A Case Of Pneumomediastinum with Subcutaneous Emphysema in a Patient of Interstitial Lung Disease


National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, New Delhi, India

Date of Web Publication28-Jun-2017

Correspondence Address:
Pushpendra K Verma
National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, B-355/A, Ashok Nagar, Mandoli Road, Near Tyagi Dairy, Delhi 110093
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_25_17

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  Abstract 

Pneumomediastinum that occurs because of rupture of alveoli and dissection of air along the fascial planes of the tracheobronchial tree is a rare complication of interstitial lung disease (ILD). Diagnosed by CAT scan, it is usually a self-limiting condition managed conservatively with supportive care and oxygen therapy. We present a rare case of pneumomediastinum with subcutaneous emphysema in a patient of ILD.

Keywords: Interstitial lung disease, pneumomediastinum, subcutaneous emphysema


How to cite this article:
Tayal N, Verma PK. A Case Of Pneumomediastinum with Subcutaneous Emphysema in a Patient of Interstitial Lung Disease. MAMC J Med Sci 2017;3:95-7

How to cite this URL:
Tayal N, Verma PK. A Case Of Pneumomediastinum with Subcutaneous Emphysema in a Patient of Interstitial Lung Disease. MAMC J Med Sci [serial online] 2017 [cited 2017 Nov 21];3:95-7. Available from: http://www.mamcjms.in/text.asp?2017/3/2/95/209020


  Introduction Top


Pneumomediastinum is the term which defines the presence of air in the mediastinum. Spontaneous pneumomediastinum is a rare complication of interstitial lung disease (ILD).[1] We present a rare case of pneumomediastinum with subcutaneous emphysema in a patient of ILD.


  Case Top


A 40-year-old male was admitted to our hospital with the chief complaints of cough for 2 years. Initially, the cough was associated with expectoration which had subsided for last 1 year. He was also complaining of progressively increasing breathlessness for similar duration and having low-grade fever for last 5 months. For these complaints, he had received antitubercular treatment 2 years ago for 6 months, but his condition did not improve. There was no history of chest pain, hemoptysis, loss of appetite, significant weight loss, orthopnea, paroxysmal nocturnal dyspnea, any skin thickening or tightness, dysphagia, Raynaud’s phenomenon, joint pain, or rashes. He was nondiabetic and nonhypertensive.

Patient was a painter by occupation. He used to do whitewashing and polishing on furniture. He also used spray paint. He was a chronic smoker (past 5 years) and also a chronic alcoholic for past 2 years. On examination, patient was having bilateral fine inspiratory crepitations predominantly on lower half of the chest. He was also having clubbing in all fingers of upper limb.

His hemoglobin was 12.1 gm/dl, total leucocyte count: 8300 cells/mm3, differential leucocyte count: Polymorphs76, Lymphocytes20, Eosinophils0 Monocytes4, serum protein: 6.44 mg/dl, serum albumin: 3.71 mg/dl, liver function tests and serum electrolytes were normal; sputum for Acid Fast Baccilli on three occasions were negative and culture for  Mycobacterium tuberculosis Scientific Name Search s also sterile. He was sero-negative for Human Immunodeficiency virus. Urine examination was within normal limits. Arterial blood gas analysis showed pH: 7.44, pCO2: 32 mmHg, pO2: 84 mmHg, HCO3: 21.6, and sPO2: 96.9%.

X-ray chest PA view [Figure 1] was showing bilateral multiple nodular shadows. CECT thorax [Figure 2] showed surgical emphysema in right chest wall, pneumomediastinum was also seen. Small, thin-walled radiolucencies in bilateral lung with basal predominance suggestive of honeycombing were present.
Figure 1: X Ray Chest PA view

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Figure 2: (a and b) CECT Thorax

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Biochemical markers showed scl70 and ribosomal-p-protein positivity, whereas Smith/ribonucleoprotein (Sm/RNP), SSA, SSB, Ro52, Jo-1, centromere B, dsDNA, nucleosome, histone, and AMA-M2 were negative. Spirometry was performed, findings of which is described in [Table 1]. Lung volumes and diffusion study could not be performed. Bronchoscopy could not be performed due to the low general condition of the patient.
Table 1: Spirometry

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Patient was managed conservatively on oxygen therapy along with other symptomatic and supportive care.


  Discussion Top


Pneumomediastinum is a relatively rare disease, and it occurs because of rupture of alveoli and dissection of air along the fascial planes of the tracheobronchial tree. It is secondary to changes in pressure gradients within the thoracic cavity due to increase in intrathoracic pressure.[2] Pneumomediastinum has been reported as a rare complication of various types of ILD,[1] which is referred as acute or chronic bilateral parenchymal infiltrative lung diseases with variable degrees of tissue inflammation and fibrosis.[3]

Hamman, in 1939, described a postpartum patient with subcutaneous emphysema and pneumomediastinum, known currently as Hamman’s syndrome.[4]

Clinically, patients with pneumomediastinum present with dyspnea, chest pain usually retrosternal radiating to the neck or the back, odynophagia, and voice hoarseness of voice.[2] Subcutaneous emphysema can be detected in 70% of patients with diagnosed pneumomediastinum.[5]

Chest CT scan is the diagnostic modality of choice to assess the extent of the pneumomediastinum, confirm the diagnosis in suspicious cases with an inconclusive chest X-ray and identify causative factors or pathologies. The presence of a pneumothorax missed on a plain chest X-ray in cases with severe subcutaneous emphysema may also be confirmed with a CT scan.[5]

Pneumomediastinum unless massive is usually a self-limiting condition. Treatment includes bed rest, analgesics for pain relief, and antitussives along with the treatment of underlying lung pathology in cases of secondary pneumomediastinum. Administration of high concentration of oxygen may increase gas absorption. Studies have shown that by breathing 100% oxygen, nitrogen is dissipated from the blood, increasing the gas absorption gradient.[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Quan SY, Danoff S, Garibaldi BT. Spontaneous pneumomediastinum in the setting of inflammatory myositis and interstitial lung disease. Chest 2009;136(4_MeetingAbstracts):53S-d-54S.  Back to cited text no. 1
    
2.
Nadig N, Thomson C. Pneumomediastinum in interstitial lung disease—a case report. Respir Med CME 2011;4:79-80.  Back to cited text no. 2
    
3.
Meyer KC, Raghu G, Baughman RP, Brown KK, Costabel U, du Bois RM et al. An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med 2012;185:1004-14.  Back to cited text no. 3
    
4.
Hamman L. Spontaneous mediastinal emphysema. Bull Johns Hopkins Hosp 1939;64:1-21.  Back to cited text no. 4
    
5.
Vasileios K. Kouritas pneumomediastinum. J Thorac Dis 2015;7(S1):S44-9.  Back to cited text no. 5
    
6.
O’Neill TJ, Johnson MC, Edwards DA, Dietz P. Ventilation with 100 percent oxygen for life-threatening mediastinal and subcutaneous emphysema. Chest 1979;76:492-3.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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