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A YOUNG LADY WITH CHEST PAIN

      1. Case description

      28-year-old woman with no significant past medical history presented with acute onset of sub-sternal chest pain at work. It was “pinching” type and got worse on deep breathing, coughing, leaning forward and drinking water. The pain was radiating to the back. She did not have any similar previous episodes. No recent strenuous workout including swimming, valsalva or other physical activity or trauma was reported. Her blood pressure was 135/80 mmHg; pulse 53/minute; respiratory rate 16/minute; temperature 98.2°F and oxygen saturation was 98% on room air. Breath and heart sounds were normal. Laboratory indices revealed normal complete blood count, basic metabolic panel and troponin. A chest radiograph (CXR) (Fig. 1A) and subsequently a computed tomographic (CT) scan of chest with intravenous contrast (Fig. 1B, 1C) was performed. A barium esophagogram was also performed (Fig. 1D). What is your diagnosis?
      Fig 1
      Fig. 1A Plain radiograph of chest showing air in middle mediastinum around the left lateral aspect of heart; B Computed tomography (CT) scan of chest with contrast, cross sectional image, showing air in anterior and middle mediastinum extending into the paravertebral soft tissues posteriorly; C Computed tomography (CT) scan of chest with contrast, coronal image, showing air extending into the soft tissue of neck; D Barium esophagogram demonstrating a normal esophagus without any perforation.

      2. Discussion

      Clinical presentation, CXR and CT chest findings led to the diagnosis of spontaneous pneumomediastinum (SP). Moderate amount of air in the anterior and middle mediastinum, and posteriorly into the paravertebral soft tissue was seen (Fig. 1B). Superiorly, air could be tracked into the soft tissue of neck (Fig. 1C). Barium esophagogram (Fig. 1D) and upper endoscopy ruled out esophageal perforation. SP is a rare condition (1 in 30,000) and may occur without any underlying pulmonary condition. 50% of cases have spontaneous etiology [
      • Bakhos C.T.
      • Pupovac S.S.
      • Ata A.
      • et al.
      Spontaneous pneumomediastinum: An extensive workup is not required.
      ]. Valsalva maneuver, straining during exercise, straining at stool, coughing, sneezing, retching or vomiting have been associated with pneumomediastinum [
      • Newcomb A.E.
      • Clarke C.P.
      Spontaneous pneumomediastinum: A benign curiosity or a significant problem?.
      ]. Depending on the extent of spread of air in the soft tissue patient may or may not be symptomatic. Most common presenting complaint is chest pain, but patients may also report dyspnea, dysphagia, neck pain, swelling and hoarse voice. Despite its alarming appearance on imaging, most cases of SP can be managed conservatively with close monitoring. A Chest tube may be needed in some cases of pneumothorax. Esophagogram is usually negative for a leak [
      • Bakhos C.T.
      • Pupovac S.S.
      • Ata A.
      • et al.
      Spontaneous pneumomediastinum: An extensive workup is not required.
      ]. Recurrence of SP occurs in only few patients (8%) with no long-term sequelae [
      • Abolnik I.
      • Lossos I.S.
      • Breuer R.
      Spontaneous pneumomediastinum; A report of 25 cases.
      ]. Identification of either a predisposing pulmonary condition or an inciting factor can be helpful. Our patient's symptoms resolved spontaneously within 2 days and remained asymptomatic at 4-week follow-up.

      FUNDING SOURCE

      None

      CONFLICT OF INTEREST

      Authors do not have any conflict of interest to disclose.

      AUTHOR CONTRIBUTIONS

      All authors had access to the data and a role in writing the manuscript.

      INFORMED CONSENT

      Informed consent was taken from the patient.

      References

        • Bakhos C.T.
        • Pupovac S.S.
        • Ata A.
        • et al.
        Spontaneous pneumomediastinum: An extensive workup is not required.
        J Am Coll Surg. 2014; 219: 713-717
        • Newcomb A.E.
        • Clarke C.P.
        Spontaneous pneumomediastinum: A benign curiosity or a significant problem?.
        Chest. 2005; 128: 3298-3302
        • Abolnik I.
        • Lossos I.S.
        • Breuer R.
        Spontaneous pneumomediastinum; A report of 25 cases.
        Chest. 1991; 100: 93-95