Pneumomediastinum and Pneumopericardium in an 11-Year-Old Rugby Player: A Case Report

Objective:

Pneumomediastinum and pneumopericardium are rare occurrences in young athletes, but they can result in potentially life-threatening consequences.

Background:

While involved in a rugby match, an 11-year-old boy received a chest compression by 3 players during a tackle. He continued to play, but 2 hours later, he developed sharp retrosternal chest pain. A chest radiograph and an echocardiograph at the nearest emergency department showed pneumopericardium and pneumomediastinum.

Differential Diagnosis:

Sternal and rib contusions, rib fractures, heartburn, acute asthma exacerbation, pneumomediastinum, pneumopericardium, pneumothorax, traumatic tracheal rupture, myocardial infarction, and costochondritis (Tietze syndrome).

Treatment:

Acetaminophen for pain control.

Uniqueness:

To our knowledge, this is the only case in the international literature of the simultaneous occurrence of pneumomediastinum and pneumopericardium in a child as a consequence of blunt chest trauma during a rugby match.

Conclusions:

Pneumomediastinum and pneumopericardium may be consequences of rugby blunt chest trauma. Symptoms can appear 1 to 2 hours later, and the conditions may result in serious complications. Immediate admission to the emergency department is required.Key Words: retrosternal chest pain, compression trauma, youth athletesPneumomediastinum (PM) and pneumopericardium (PP) are conditions in which air is present in the mediastinal and pericardial spaces, respectively. The mediastinum is the central compartment of the thoracic cavity and contains the heart and great vessels, trachea, esophagus, phrenic and cardiac nerves, thoracic duct, thymus, and lymph nodes. It extends from the sternum in the front to the vertebral column in back. The pericardium is a double-walled sac that contains the heart and the roots of the great vessels. The pathogenesis of PM and PP during a thoracic compression is probably an increase in intra-alveolar pressure; alveolar overdistention results in rupture of alveolar walls, allowing air to travel through the pulmonary interstitium along the perivascular sheaths to the lung hilum and mediastinum and the pericardial reflection.^1–3 Pericardial connective tissue is discontinuous at the lines of reflection of the parietal pericardium near the ostia of the pulmonary veins, creating a site of potential weakness where microscopic dissection of air into the pericardial sac is possible.^1,2,4–6Pneumomediastinum can be spontaneous, occurring without an evident primary cause, or secondary to underlying and predisposing conditions, such as asthma, bronchiolitis obliterans, tobacco smoke, illegal drug ingestion, or blunt thoracic trauma. In the case of trauma, PM is more serious due to the likely association with other injuries and the higher risk of complications.^7,8 In a series of 986 children admitted to the trauma center of an emergency department, PM accounted for 0.6% of thoracic injuries.⁹Pneumopericardium is typically secondary to recent heart surgery or to blunt or penetrating trauma,¹⁰ but it can also occur with infectious pericarditis from gas-producing organisms or from a fistula formation between the pericardium and an adjacent air-containing organ.¹¹In children, PM and PP are rarely reported simultaneously^12–15 and even less often as complications of trauma during sports.^11,16 In the latter condition, PP is secondary to PM when great forces applied to the chest provoke the passage of air from the mediastinal space to the pericardial space.¹⁷ We report a case of chest pain secondary to PM and PP in a child as a result of blunt chest trauma during a tackle in a rugby match.