Rare disease

Case report

Case of chest pain in a young man

Ankit Gupta,1 Atul Vijay Palkar,1 Priya Narwal2

1
Pulmonary and Critical Care Summary
Medicine, Hartford HealthCare, A young man with a history of smoking presented with
Hartford, Connecticut, USA acute-onset chest pain after lifting weights. He also
2
Rhode Island Hospital,
noticed a change in his voice, tightness in his neck and
Providence, Rhode Island, USA
difficulty breathing. A chest radiograph showed soft
tissue emphysema in the neck. A CT scan of the chest
Correspondence to
Dr Ankit Gupta, revealed moderate amount of pneumomediastinum
​ankitguptapulmonary@​gmail.​ tracking into the neck and down to the diaphragm.
com He was haemodynamically stable and had no hypoxia
or dysphagia. He was monitored for 48 hours and
Accepted 1 January 2018 discharged home after resolution of his symptoms. A
chest radiograph repeated after 6 weeks was normal.

Background
This case describes a rare cause of chest pain in the Figure 2  CT soft tissue neck: moderate amount of
young. Pneumomediastinum without any compli- pneumomediastinum and soft tissue emphysema in the
cations can be managed with supportive treatment. neck.

Case presentation sounds. Hamman’s sign was not appreciated. The

A 19-year-old man, an occasional cigarette and rest of his examination was unremarkable.
marijuana smoker, presented to the emergency
department with sudden onset of right-sided pleu- Investigations
ritic chest pain and shortness of breath while lifting ECG showed sinus tachycardia. Chest and neck
heavy weights. He also noticed a change in his voice, radiograph showed prevertebral soft tissue emphy-
tightness in his neck and shortness of breath devel- sema in the lower neck and upper mediastinum
oping over the next few hours. He was premorbidly (figure 1). CT of the neck and chest confirmed
healthy and did not take any medications. He had moderate pneumomediastinum without any pneu-
no medical history of asthma/bronchitis. mothorax or lung parenchymal abnormalities
On physical examination, his temperature was (figure 2 and figure 3).
36.7 Celsius, pulse was 102 beats per minute, respi-
ratory rate was 20 breaths per minute, blood pres-
Differential diagnoses
sure was 118/70 mm Hg and oxygen saturation was
►► asthma exacerbation
97% on room air (RA). He looked mildly distressed
►► primary spontaneous pneumothorax.
on initial presentation and had crepitus around
his neck. There was no jugular venous distension.
Treatment
Auscultation of his lungs revealed no adventitious
The patient was treated with inhaled bronchodila-
tors on an as-needed basis and analgesics.

To cite: Gupta A, Palkar AV,

Narwal P. BMJ Case Rep
Published Online First: Figure 3  CT chest: pneumomediastinum, extending
[please include Day Month from the level of the skull base down to the level of the
Year]. doi:10.1136/bcr-2017- Figure 1  Soft tissue neck X-ray: prevertebral soft tissue gastro esophageal  (GE) junction. Extraluminal gas also
222756 emphysema. extends along the bronchovascular bundles at both hila.
Gupta A, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-222756 1
Rare disease
Outcome and follow-up chronic bronchitis, respiratory tract infections, vomiting,
He was observed for 48 hours in the hospital. He had no choking and Valsalva manoeuvre including weightlifting.3 The
dysphagia and his shortness of breath slowly subsided. His chest most commonly reported symptoms include chest pain, neck
X-ray at discharge was unchanged. pain, dyspnoea, dysphagia and swelling of the face and neck.4
He was prescribed a rescue inhaler on an as-needed basis, and Diagnosis can often be confirmed by posteroanterior and lateral
was advised to avoid strenuous activity and air travel for a few chest radiography alone, but some authors recommend CT as the
weeks. gold standard test.5 We were able to find only one similar case
A follow-up chest X-ray at 6 weeks showed complete reso- report in literature where SPM was directly related to weight-
lution of the subcutaneous emphysema. He did not have any lifting.6 Conservative management with analgesics and oxygen is
recurrence at 6 months. often used with good outcomes.7 Recurrences are rare.8

Discussion Contributors  AG, AVP and PN were all involved in writing the manuscript,
literature review and proof-reading.
Spontaneous pneumomediastinum (SPM) is a rare cause of chest
pain.1 It is more common in young men. It usually occurs due Competing interests  None declared.
to a sudden increase in intra-alveolar pressure during pressure Patient consent  Obtained.
swings in the thoracic cavity with alveolar rupture into the Provenance and peer review  Not commissioned; externally peer reviewed.
bronchovascular sheath.2 Predisposing factors include asthma, © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article)
2018. All rights reserved. No commercial use is permitted unless otherwise expressly
granted.
Patient’s perspective
References
“I have been very active all my life but was new to weight 1 Tobushi T, Hosokawa K, Matsumoto K, et al. Exercise induced spontaneous
training at the time of the incidence which was scary. I thought I pneumomediastinum. Int J Emerg Med 2015;8:43.
2 Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to
was having a heart attack. Once the diagnosis was made, I was
mediastinum. Arch Intern Med 1939;64:913.
given the option for surgery which scared me even more. I am 3 Wong KS, Wu HM, Lai SH, et al. Spontaneous pneumomediastinum: analysis of 87
glad I could avoid surgery.” pediatric patients. Pediatr Emerg Care 2013;29:988.
4 Dirweesh A, Alvarez C, Khan M, et al. Spontaneous pneumomediastinum in a healthy young
female: a case report and literature review. Respir Med Case Rep 2017;20:129–32.
5 Kaneki T, Kubo K, Kawashima A, et al. Spontaneous pneumomediastinum in 33
Learning points patients: yield of chest computed tomography for the diagnosis of the mild type.
Respiration 2000;67:408–11.
6 Nishino T. Spontaneous pneumomediastinum after bench press training. Clin Case Rep
►► Spontaneous pneumomediastinum (SPM) is very
2017;5:535–6.
uncommon. 7 Takada K, Matsumoto S, Hiramatsu T, et al. Management of spontaneous
►► Weight training in the young can cause SPM. pneumomediastinum based on clinical experience of 25 cases. Respir Med
►► SPM can be managed with careful observation. 2008;102:1329–34.
►► Recurrence is rare. 8 Grossman A, Romem A, Azaria B, et al. Pneumomediastinum in student aviators: 10
cases with return to flying duty. Aviat Space Environ Med 2005;76:63–5.

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2 Gupta A, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-222756

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