Case Report Tropical Doctor 0(0) 1–2 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0049475520960872 journals.sagepub.com/home/tdo

Pneumoperitoneum from pneumomediastinum in paraquat poisoning Noel James1, Rohit Bakshi1, SS Rudresh1, Karanti Kaushik2, Kanwarnavjot Singh Ghumaan2 and Ashok Kumar Pannu3

Abstract Pneumomediastinum is not uncommon in paraquat poisoning and usually results from oesophageal perforation or alveolar rupture in fibrotic lung disease. However, the combined presentation of pneumomediastinum and pneumoperitoneum is a rarity. We recently managed a young patient with paraquat ingestion who developed spontaneous pneumomediastinum. His chest radiograph also showed free air under the right hemidiaphragm. This pneumoperitoneum caused no clinical symptom and resolved spontaneously within a few days without any surgical intervention.

Keywords Pneumoperitoneum, pneumomediastinum, paraquat

Case report A 19-year-old man was admitted to our emergency department with tongue ulcers, jaundice and decreased urine output after ingestion of paraquat dichloride for intentional self-harm, two days before his presentation (Figure 1). At admission, his respiratory rate was 16 breaths per minute, his oxygen saturation was 96% on ambient air and the chest radiograph was normal. He gradually developed progressive shortness of breath and cough. A repeat chest radiograph showed pneumomediastinum, subcutaneous emphysema of the neck and chest wall, small left-sided pneumothorax and pneumoperitoneum with free air under the right hemidiaphragm (Figure 2a). He did not have abdominal pain or tenderness, and the pneumoperitoneum was thought to have resulted from extension of the pneumomediastinum. Without any intervention, the free air resolved spontaneously (Figure 2b). However, our patient developed diffuse parenchymal lung involvement with fibrosis and subsequently died of multiorgan failure despite supportive care, methylprednisolone and haemodialysis.

Discussion Pneumomediastinum is not uncommon in paraquat poisoning and usually results from oesophageal

ulceration and perforation or alveolar rupture in fibrotic lung disease.1,2 However, the combined presentation of pneumomediastinum and pneumoperitoneum seems not to have been previously reported. The common causes are barotrauma from mechanical ventilation, severe asthma, excessive cough, chest trauma, oesophageal rupture and various endoscopic procedures. Pneumoperitoneum secondary to pneumomediastinum results from air tracking along fascial planes or through the foramina of Morgagni and Bochdalek. The condition in this setting causes no clinical symptom and resolves spontaneously within a few days without any invasive intervention.3,4

1 Senior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India 2 Junior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India 3 Assistant Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Corresponding author: Ashok Kumar Pannu, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Chandigarh, India. Email: [email protected]

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Figure 1. Photograph showing extensive ulceration with greenish necrotic slough over the dorsum of the tongue (paraquat tongue) and deep icterus.

Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD Ashok Kumar Pannu 3478

https://orcid.org/0000-0002-4476-

Figure 2. (a) Chest radiograph showing pneumomediastinum with free air in the mediastinum and continuous diaphragm sign (black arrowheads), subcutaneous emphysema of neck and chest wall (white arrowheads), left-sided mild pneumothorax (black arrow) and pneumoperitoneum with free air under the right hemidiaphragm (white arrow). (b) Follow-up chest radiograph showing free air resolution, but the appearance of bilateral reticuloalveolar opacities suggests diffuse parenchymal lung disease.

References 1. Zhou CY, Kang X, Li CB, et al. Pneumomediastinum predicts early mortality in acute paraquat poisoning. Clin Toxicol (Phila) 2015; 53: 551–556. 2. Im JG, Lee KS, Han MC, et al. Paraquat poisoning: findings on chest radiography and CT in 42 patients. AJR Am J Roentgenol 1991; 157: 697–701.

3. Lantsberg L and Rosenzweig V. Pneumomediastinum Causing Pneumoperitoneum. Chest 1992; 101: 1176. 4. Kourounis G, Lim QX, Rashid T, et al. A rare case of simultaneous pneumoperitoneum and pneumomediastinum with a review of the literature. Ann R Coll Surg Engl 2017; 99: e241–e243.