Spontaneous pneumomediastinum,pneumothorax and subcutaneous emphysema: Radiological aspects of rare COVID-19 complications in 3 patients

Spontaneous pneumomediastinum (SPM), pneumothorax (PNX) and subcutaneous emphysema are rare complications of COVID-19 pneumonia. In this paper we describe 3 cases of COVID-19 pneumonia complicated by SPM with or without PNX. Patient 1 was a 56-year-old woman whose medical history was significant for chronic leukemia. She presented with typical clinical signs of COVID-19 pneumonia and after 2 weeks of hospitalization she developed SPM and subcutaneous emphysema. The management of pneumomediastinum (PNM) was conservative and follow-up computed tomography showed resolution of PNM. Patient 2 was a 67-year-old man presenting with fever, cough and dyspnea. Computed tomography pulmonary angiography was performed after 2 weeks of hospitalization and showed bilateral peripheral consolidations together with massive PNM and right-sided PNX. Thoracic drainage catheter was inserted in his right chest. Despite all supportive care, the patient succumbed to illness. Patient 3 was a 74-year-old man who was admitted to our hospital with COVID-19 pneumonia and spontaneous right-sided PNX. A thoracic drainage catheter was inserted immediately and then removed after ten days which has led to progression of subcutaneous emphysema, PNX and newly diagnosed PNM. Patient was carefully monitored for the next 2 weeks. Follow-up chest x-ray showed regression of PNM and PNX. SPM, PNX and subcutaneous emphysema are rare complications of COVID-19 pneumonia. Increased alveolar pressure and diffuse alveolar injury in severe COVID-19 pneumonia may make the alveoli more prone to rupturing which leads to gas dissemination along the peribronchovascular sheath to the mediastinum. Most cases of SPM and PNX resolve with conservative management.     

Spontaneous pneumothorax and pneumomediastinum in IPF

Patients with idiopathic pulmonary fibrosis (IPF) are at risk for a variety of acute pulmonary complications, including pneumothorax and pneumomediastinum. Our aim was to describe the radiographic and CT findings and to determine the frequency of complicating spontaneous pneumothorax and pneumomediastinum in patients with IPF. A retrospective study was performed including 78 consecutive patients who underwent CT scanning of the chest and who had confirmed IPF. The chest radiographs and CT scans were reviewed by two chest radiologists and classified as showing features of extra-alveolar air collections. The CT scans showed extra-alveolar air in 9 (11.2 %) of 78 patients (six females and three males; age range 26–90 years, mean age 65 years). Pneumothorax was demonstrated in 5 patients and mediastinal air collections in 4 patients. All patients had dyspnea for 1–48 months (mean 14 months). Of the five cases with pneumothorax, four developed acute onset of dyspnea and pleuritic chest pain, whereas 1 patient had a relatively stable functional status. Of the 4 patients with pneumomediastinum, three presented with nonpleuritic chest pain and acute dyspnea. Chest radiographs showed extra-alveolar air in 6 patients. Three cases were predicted to be negative by chest radiographs. Follow-up CT showed that air collections had resolved completely in 5 patients. Two patients died of respiratory failure within 4 months after CT. Extra-alveolar air should be recognized as a relatively common IPF-related complication. Chest CT is a useful imaging method in determining air collections in patients with IPF that become acutely breathless and their chest radiograph fails to reveal the presence of extra-alveolar air. Received: 9 October 1998; Revised: 26 January 1999; Accepted: 6 April 1999     

Spontaneous pneumomediastinum and subcutaneous emphysema after masturbation

Spontaneous pneumomediastinum is a rare condition that mostly affects young men and generally follows a benign and self-limiting course. In contrast to secondary pneumomediastinum, which is caused by trauma, iatrogenic intervention or esophageal perforation, spontaneous pneumomediastinum is triggered by violent coughing, excessive vomiting, strenuous physical exercise or Valsalva maneuver. It results from an abrupt increase in intrathoracic pressure leading to alveolar rupture and air leak along the tracheobronchial tree into the mediastinal cavity. Extended spontaneous pneumomediastinum goes along with subcutaneous emphysema of the chest, neck or head. We present a case of a healthy young man who developed pneumomediastinum and profound subcutaneous emphysema with onset during masturbation. Since there is no literature on spontaneous pneumomediastinum associated with autoerotic experiences, we consider our case an unusual presentation of this entity.     

Subcutaneous emphysema in status asthmaticus

Spontaneous subcutaneous accumulations of air in the soft parts of the thorax during an asthmatic crisis (status asthmaticus) are rarely seen. The pathomechanism of the phenomenon, which may lead to the formation of an emphysema of the soft parts via the pneumomediastinum, is discussed, and the possible complications which must be taken into account are pointed out. The value of radiological examination of the thorax in children suffering from asthma bronchiale, is explained briefly.     

Erosive gastritis,Armanni-Ebstein phenomenon and diabetic ketoacidosis

The Armanni-Ebstein phenomenon, which is found in the kidneys in diabetic ketoacidosis, has also been proposed as an independent diagnostic postmortem marker for hypothermia. A case is reported to demonstrate the possibility of a more complex inter-related etiology in certain instances. A 44-year-old man with a past history of hospital admission for hypothermia, alcoholism and insulin dependent diabetes mellitus was found dead at his home address. At autopsy there were prominent superficial erosive gastritis (Wischnewsky spots) in keeping with terminal hypothermia. In addition there was also marked cortical pallor of the kidneys due to subnuclear renal tubular epithelial vacuolization (Armanni-Ebstein phenomenon). Thus there was evidence for both hypothermia and Armanni-Ebstein phenomenon, suggesting a relationship. Subsequent biochemical testing of vitreous humor, however, demonstrated markedly elevated levels of glucose (36.5 mmol/l; N = 3.6–6.0 mmol/l), β-hydroxybutyrate (23.2 mmol/l; N < 0.3 mmol/l), and lactate (29.4 mmol/l; N = 0.2–2.0 mmol/l). Death was, therefore, due to diabetic ketoacidosis complicated by hypothermia. Diabetes mellitus has a known association with both hypothermia and Armanni-Ebstein phenomenon, thus, before renal tubular vacuolization can be taken as a marker of hypothermia in isolation, it is important to consider the possibility that in certain cases underlying diabetic ketoacidosis may be present.     

Spontaneous subcutaneous emphysema and pneumomediastinum in non-intubated patients with COVID-19

PurposeWe describe the presenting characteristics and hospital course of 11 novel coronavirus (COVID-19) patients who developed spontaneous subcutaneous emphysema (SE) with or without pneumomediastinum (SPM) in the absence of prior mechanical ventilation.Materials and methodsA total of 11 non-intubated COVID-19 patients (8 male and 3 female, median age 61 years) developed SE and SPM between March 15 and April 30, 2020 at a multi-center urban health system in New York City. Demographics (age, gender, smoking status, comorbid conditions, and body-mass index), clinical variables (temperature, oxygen saturation, and symptoms), and laboratory values (white blood cell count, C-reactive protein, D-dimer, and peak interleukin-6) were collected. Chest radiography (CXR) and computed tomography (CT) were analyzed for SE, SPM, and pneumothorax by a board-certified cardiothoracic-fellowship trained radiologist.ResultsEleven non-intubated patients developed SE, 36% (4/11) of whom had SE on their initial CXR. Concomitant SPM was apparent in 91% (10/11) of patients, and 45% (5/11) also developed pneumothorax. Patients developed SE on average 13.3 days (SD: 6.3) following symptom onset. No patients reported a history of smoking. The most common comorbidities included hypertension (6/11), diabetes mellitus (5/11), asthma (3/11), dyslipidemia (3/11), and renal disease (2/11). Four (36%) patients expired during hospitalization.ConclusionSE and SPM were observed in a cohort of 11 non-intubated COVID-19 patients without any known cause or history of invasive ventilation. Further investigation is required to elucidate the underlying mechanism in this patient population.     

Subcutaneous emphysema: diagnostic clue in the emergency room

The objective of this study was to illustrate the wide spectrum of subcutaneous emphysema in the emergency room; to show the key findings on computed tomography, plain radiographs, and echography; and to discuss the differential diagnoses. Subcutaneous emphysema is a common finding in emergency department imaging studies. It has a great importance due to its broad casualty, some of them totally benign, but others potentially lethal. We retrospectively reviewed our database of emergency pathology, analyzing its origins and associated features. SE was associated to traumatic, iatrogenic, or infectious causes (necrotizing fasciitis, Fournier gangrene). It also was found associated with thoracic (causing pneumothorax and pneumomediastinum) and abdominal pathology related to intraperitoneal and retroperitoneal gas. Diagnostic difficulties and differential diagnoses are emphasized. Radiologists must be aware of abnormal gas in soft tissue because it may be the main or unique sign leading to an underlying pathology, which can be lethal.     

Subcutaneous emphysema as a complication of tooth extraction

Subcutaneous emphysema is a rare complication in dentistry, which may lead to diagnostic errors and inadequate therapy. A 17 year old female patient, in whom the separation of tooth roots was performed by the use of air-powered drill during the extraction of the first right lower molar, is presented in this paper. During the intervention, swelling of the right half of the face and the lower eyelid suddenly occurred, accompanied with simultaneous feeling of choking, and pressure in the neck and chest. Because of the suspicion of the allergic reaction, the patient was administered antihistaminic agent, together with parenteral corticosteroid, and was sent to an institution where she was treated as an in-patient. During hospitalization, subcutaneous emphysema of the face and neck was diagnosed by physical and x-ray examination. The emphysema completely disappeared after the use of oxygen and antibiotics.     

Fatal bilateral pneumothorax and generalized emphysema following contraindicated speaking-valve application

Forensic Science, Medicine and Pathology - We report a case of a contraindicated attachment of a speaking valve to a tracheal tube with an inflated cuff, which rapidly resulted in the...     

Cranial CT in children and adolescents with diabetic ketoacidosis

To determine the effects of diabetic ketoacidosis on the brain, we studied nine consecutive patients between the ages of 6 and 17 years by performing cranial CT on three occasions: on admission, before treatment; 6-8 hr after beginning treatment; and 7 days after admission. Both the pretreatment scans and those at 6-8 hr showed significantly reduced size of the lateral and third ventricles in comparison with the 7-day scans. A comparison of the pretreatment scans with those done at 6-8 hr showed no statistically significant differences. We conclude that the cerebral swelling of diabetic ketoacidosis is usually present before treatment.     

Iatrogenic pneumomediastinum and subcutaneous emphysema as a complication of colonoscopy with cold forceps biopsy

A 58-year-old woman underwent outpatient colonoscopy with multiple cold forceps biopsy for evaluation of a presumptive diagnosis of ulcerative colitis. Six hours following the procedure, she developed subcutaneous crepitus and presented to the emergency department, where chest X-ray revealed pneumomediastinum and subcutaneous emphysema. Our case discusses this unusual complication of colonoscopy and its diagnosis and management.