Recurrent spontaneous pneumomediastinum: a rare but possible
event!
1Thoracic Surgery Unit, Second Unversity of Naples, Naples, Italy; 2Bronchoscopic Unit, Public Hospital, Eboli, Italy
Case Report
Recurrent spontaneous pneumomediastinum: a rare but possible
event!
1Thoracic Surgery Unit, Second Unversity of Naples, Naples, Italy; 2Bronchoscopic Unit, Public Hospital, Eboli, Italy
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Abstract
Recurrent spontaneous pneumomediastinum is an exceptional event and little is known about it.
We report an exceptional case of patient who presents with early recurrence of spontaneous pneumomediastinum following a spasm of coughing and in absence of any predisposing factors. The episodes of pneumomediastinum were elicited by recurrent episode of coughing and resolved with medical treatment. Despite rare, recurrence of spontaneous pneumomediastinum is a possible event which may occur in patients without predisposing factors. Key words
Empyema; hematology; lung; thoracotomy
J Thorac Dis 2012;4(4):431-433. DOI: 10.3978/j.issn.2072-1439.2012.07.17 |
Introduction
Recurrent spontaneous pneumomediastinum (SPM) is an
exceptional event and little is known about it. We report an
exceptional case of patient who presented with early recurrence
of SPM following spasm coughing. In both episodes, SPM
resolved with medical treatment.
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Case report
In December 2010, a 16 years-old man was admitted to a
local hospital for complaints of chest pain, dyspnea, and neck
pain presenting after spasm coughing. His medical history
was unremarkable. Chest X-Ray and CT scan diagnosed
the presence of pneumomediastinum without signs of
pneumothorax and/or pleural effusion (Figure 1A). Thus,
the patient was transferred to our hospital for diagnosis and
treatment. Bronchosopic was attempted, but no endotracheal
lesions were found. Gastrografin swallow excluded any
esophageal perforation. Thus, the diagnosis of SPM was made.
Medical treatment was done (reassurance, bed rest, oxygen,
analgesic, and antibiotic therapy) with gradual improvement
of clinical condition. Chest CT scan performed after 9 days,
showed the complete disappearance of pneumomediastinum
with no evidence of bullae (Figure 1B).
Figure 1. Massive emphysema of the superior mediastinum, around the trachea and vessels (A). Complete disappearence of
pneumomediastinum (B).
Following four days, the patient presented again at our
unit for complaint of persistent chest pain and dyspnea which
presented again after coughing. Radiological evaluation
diagnosed the presence of pneumomediastinum (Figure 2A).
All laboratory and diagnostic tests were within normal. Yet, the
patient underwent bronchial hyperreactivity test which resulted
as negative Thus, he was managed as before and discharged
after 7 days. CT scan diagnosed the complete resolution of
pneumomediastinum without sequel (Figure 2B).
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Discussion
SPM was firstly described by Louis Hamman in 1939 (1). It
is defined as the presence of interstitial air in the mediastinum
without any apparent precipitating factor (2). Alveolar
rupture leads to the accumulation of air in the interstitium that
circulates centripetally through the venous sheats to the hilum
and mediastinum (3). This occurs because the pressure in the
mediastinum is lower than that of lung periphery. The most
common symptoms are chest pain, dyspnea, and neck pain as
observed in our case. If chest X-ray is negative, chest CT scan
should be performed because up to 30% of patients with SPM
have normal chest –X-ray as reported by Kaneki (4); yet, chest
CT is useful to exclude undiagnosed chest pathologies. SPM is a
benign condition that generally resolves with medical treatment
(5,6). In our experience, we have observed five cases of SPM,
of which one occurred just following extubation in a patient
undergoing elective breast reduction for gynecomastasia (7).
Our experience confirms the previously reported benign nature
of this condition.
Recurrent SPM is an exceptional event, and little is known about
it; in English literature only three cases of recurrent SPM are reported
in the series of Albonik et al. (8), Gerazounis et al. (9), and Macia et
al. (1), respectively. It seems reasonable to think that recurrences
of SPM are facilitated by the persistence of predisposing factor
(e.g., asthma, interstitial lung disease, pneumonia, bullous lung,
and radiation therapy for lung cancer) or when a casual situation
happens again.
In the present case, at the time of the first episode
of pneumomediastinum differential diagnosis includes
pulmonary disease, tracheal bronchial rupture, and Boerhaave’s
syndrome. However, radiological findings show the presence
of pneumomediastinum without any signs of other diseases.
Additional diagnostic tests including contrast-enhanced swallow
study and bronchoscopy illustrate no-significant abnormalities.
Thus, the diagnosis of SPM is made according to the criteria of
Macia et al. (2) as following: (i) the presence of a clinical picture
consistent with pneumomediastinum; (ii) the absence of a clearly
defined triggering cause; (iii) the presence of interstitial air in the
mediastinum; (iv) and the patient older than 13 years of age. The
medical treatment is made with resolution of pneumomediastinum
9 days later.
When the patient returns again to our unit for the presence of
pneumomediastinum, we focus regarding the possible cause of
the early recurrence of SPM.
The presence of predisposing factor as asthma, interstitial
lung disease, pneumonia, bullous lung, and radiation therapy
for lung cancer are ruled-out by clinical history and radiological
findings. Yet, bronchial hyperreactivity tests result as negative.
Thus, in our case the recurrent episodes of coughing may cause
SPM as confirmed by review of patient’s history, but remains
unclear how spasm coughing may cause the alveolar rupture in
absence of respiratory disease and of use of illicit drug, often
reported as predisposing factor of pneumomediastinum.
Finally, our case shows that the recurrence of SPM is a
possible event also in patient without predisposing factors.
An open question is the follow-up of such patients. Certainly,
we should tell the patient with an episode of SPM to avoid
certain practices as scuba diving especially if above-mentioned
predisposing factors are present.
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Acknowledgements
Disclosure: The authors declare no conflict of interest.
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References
Cite this article as: Fiorel li A , Messina G,
Capaccio D, Santini M. Recurrent spontaneous
pneumomediastinum: a rare but possible event! J
Thorac Dis 2012;4(4):431-433. doi: 10.3978/
j.issn.2072-1439.2012.07.17
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