Case study of Diffuse Subcutaneous Emphysema

Dr Tiffany M. St at UNC Health Care System, Chapel Hill, NC and colleagues have reported a rare case of Diffuse Subcutaneous Emphysema. The case has appeared in the New England Journal of Medicine.

Pneumomediastinum and subcutaneous emphysema are often a result of spontaneous alveolar wall rupture or, more rarely, of disruption of the upper airways or gastrointestinal tract and are related to the presence of air within the mediastinal cavity or in the subcutaneous tissue, respectively. The clinical symptoms of mediastinal and/or subcutaneous emphysema critically depend on the amount of extravasated gas and the degree of extension of the affected areas. Most frequently, they include swelling and crepitus over the involved anatomical site, as well as chest pain, dyspnoea, and dysphagia.

According to history a 14-year-old boy with a history of asthma presented to the emergency department with a 1-day history of wheezing and coughing. His initial oxygen saturation was 83% while he was breathing ambient air, and the physical examination was notable for diffuse wheezing and the use of accessory muscles of ventilation. He received albuterol, ipratropium, intravenous magnesium, and intravenous glucocorticoids and was admitted to the hospital for a severe asthma exacerbation.

Two days later, he had worsening respiratory distress and wheezing and was transferred to the pediatric intensive care unit for continuous albuterol treatment. Swelling and crepitus of the neck also developed. Among the findings on his chest radiograph was a pneumomediastinum (Panel A, arrow) with diffuse subcutaneous emphysema. Four days later, as his respiratory status improved, sudden swelling and palpable crepitus developed in both cheeks and the right eyelid (Panel B).

He had no associated eye pain or diplopia, and extraocular movements were intact. Palpebral emphysema can occur as a complication of pneumomediastinum and typically resolves without intervention. On hospital day 7, the patient’s asthma exacerbation resolved and he was discharged home with intermittent albuterol treatment and a tapering course of prednisone. The eyelid swelling resolved slowly over 2 weeks.

For more details click on the link: DOI: 10.1056/NEJMicm1811009