XML Template (2015) [30.4.2015–10:22am] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/150063/APPFile/SG-AANJ150063.3d
(AAN)
[1–3] [PREPRINTER stage]
Case Study
Spontaneous pneumomediastinum: A complication of swine flu
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315585907 aan.sagepub.com
Ajit Kumar Padhy, Anubhav Gupta, Palash Aiyer, Narender Singh Jhajhria, Vijay Grover and Vijay Kumar Gupta
Abstract The occurrence of spontaneous pneumomediastinum in swine flu, or H1N1 influenza A infection, is a rare phenomenon and only few cases have been reported in children. We describe a case of spontaneous pneumomediastinum in adult infected with swine flu.
Keywords Adult, Influenza A virus, H1N1 subtype, Influenza, human, Mediastinal emphysema
Introduction The occurrence of spontaneous pneumomediastinum (SPM) in swine flu, or H1N1 influenza A infection, is a rare phenomenon and only few cases of SPM have been reported in children. To the best of our knowledge, this is the first report of a case of SPM in an adult infected with swine flu.
Case report A 32-year-old man presented to our institute with history of cough, fever, and dyspnea for 5 days. Examination revealed tachypnea, bilateral rhonchi, and diminished vesicular sounds in the bilateral lower zone. Palpable crepitations were present over the neck and chest wall. A nasal swab was positive for H1N1 infection. A chest radiograph (Figure 1) indicated surgical emphysema in the neck and chest wall, as well as bilateral pleural effusions. Contrast-enhanced computed tomography of the chest revealed surgical emphysema in the myofascial planes of neck and chest wall, with pneumomediastinum, bilateral pleural effusions, and bilateral lower lobe consolidation (Figure 2). Spontaneous resolution of pneumomediastinum, subcutaneous emphysema, and pneumonia occurred after treatment with oseltamivir phosphate, cephalosporins, and bilateral intercostal tube drainage.
Discussion The clinical presentation of swine flu varies from a mild self-limiting febrile respiratory tract infection to
dreaded complications such as secondary bacterial pneumonia, pneumomediastinum, and respiratory failure.1 SPM as a complication of swine flu was first described in one Mexican patient,2 and another two patients in Japan.3 Three cases of SPM related to pandemic H1N1 influenza associated with air leak syndrome were reported in Ottawa, Canada.4 In India, only one case has been reported so far,5 but all of the cases reported so far belong to pediatric population (Table 1). To the best of our knowledge, our case is the first adult who developed SPM in swine flu. SPM is typically triggered by respiratory infection and inflammation. Any rise in intrathoracic pressure causes rupture of alveoli or pneumatoceles near the mediastinal pleura, leading to air dissection along the bronchovascular sheath, because air tends to follow the path of least resistance, which in turn, causes pulmonary interstitial emphysema and pneumomediastinum. In addition, air leak through the interstitium into the hilum and the neck along the deep fascial planes and subsequently, the subcutaneous planes, leads to subcutaneous emphysema in the neck and Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research and Dr Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India Corresponding author: Ajit Kumar Padhy, Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research and Dr Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, Delhi 110001, India. Email: drajitpadhy@gmail. com
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 26, 2015
XML Template (2015) [30.4.2015–10:22am] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/150063/APPFile/SG-AANJ150063.3d
(AAN)
[1–3] [PREPRINTER stage]
2
Asian Cardiovascular & Thoracic Annals 0(0)
Figure 1. Radiographs of neck and chest showing subcutaneous emphysema with bilateral pleural effusion (arrows).
Figure 2. Computed tomography demonstrating subcutaneous emphysema in the myofascial planes of the neck and thorax with pneumomediastinum.
chest wall.6 In severe pneumomediastinum, the trapped air can cause airway obstruction or impingement on venous return by a tamponade effect.6 SPM should be suspected in the presence of subcutaneous emphysema in the neck and chest wall region. SPM may be missed
because of its subtle clinical manifestations such as cough, dyspnea, neck pain, chest pain, and odynophagia.6 The diagnosis is confirmed by imaging. Although plain radiographic findings including air streaks outlining the mediastinal structures, especially around the
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 26, 2015
XML Template (2015) [30.4.2015–10:22am] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/150063/APPFile/SG-AANJ150063.3d
(AAN)
[1–3] [PREPRINTER stage]
Padhy et al.
3
Table 1. Details of patients with spontaneous pneumomediastinum in swine flu in previous reports. Author
Year
Dawood2 Hasegawa3
2009 2010
Udupa4
2011
Patra5
2011
Age (years)/Sex Not reported 6/F 8/M 9/F 3/M 7/F
Clinical presentation
Treatment
Outcome
SPM Fever, respiratory distress, SPM Fever, chest pain, dyspnea, SPM Cough, neck swelling, diarrhoea, SPM Fever, cough, neck swelling, SPM Fever, respiratory distress, skin rash, SPM
Not reported Antiviral, bronchodilators Antiviral, bronchodilator Antiviral, bronchodilator, antibiotics Antiviral, bronchodilators, antibiotics Antiviral, antibiotics, tracheostomy
Not reported Recovered Recovered Recovered Recovered Died
SPM: spontaneous pneumomediastinum.
tracheostomy is lifesaving in these cases (Figure 3),5,6 which can be performed at the bedside under local anesthesia. SPM is a very unusual complication of swine flu and should be looked for in the presence of subcutaneous emphysema. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References Figure 3. Cervical mediastinotomy: the cervicomediastinal fascial continuity is entered by a suprasternal transverse incision below the level of cricoids cartilage. The anterior surface of the trachea is reached by retracting the sternohyoid and sternothyroid muscles and dissecting the pretracheal layer of the deep cervical fascia. Further down, the retrovascular plane is entered by finger dissection, passing first behind the innominate vessels (IV), aortic arch, and pulmonary artery (PA), and then down below the level of carina and along both sides of the trachea and main bronchi for approximately 2 cm.
cardiac landmarks, are diagnostic, computed tomography has greater sensitivity for the detection of pneumomediastinum and is considered the gold standard for diagnosis.6 SPM usually resolves within a few days with supportive care which includes analgesia, rest, and treatment of the underlying medical condition.6 Surgical intervention has rarely been described in pneumomediastinum; its use is reserved for pneumomediastinum leading to marked cardiorespiratory compromise. Cervical mediastinotomy with or without
1. Soto-Abraham MV, Soriano-Rosas J, Dı´ az-Quin˜o´nez A, et al. Pathological changes associated with the 2009 H1N1 virus. N Engl J Med 2009; 361: 2001–2003. 2. Dawood FS, Jain S, Finelli L, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med 2009; 360: 2605–2615. 3. Hasegawa M, Hashimoto K, Morozumi M, Ubukata K, Takahashi T and Inamo Y. Spontaneous pneumomediastinum complicating pneumonia in children infected with 2009 pandemic influenza A (H1N1) virus. Clin Microbiol Infect 2010; 16: 195–199. 4. Udupa S, Hameed T and Kovesi T. Pneumomediastinum and subcutaneous emphysema associated with pandemic (H1N1) influenza in three children. CMAJ 2011; 183: 202–212. 5. Patra PK, Nayak US and Sushma TS. Spontaneous pneumomediastinum in H1N1 infection. Indian Pediatr 2011; 48: 976–977. 6. Caceres M, Ali SZ, Braud R, Weiman D and Garrett HE Jr. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg 2008; 86: 962–966.
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 26, 2015
(AAN)
[1–3] [PREPRINTER stage]
Case Study
Spontaneous pneumomediastinum: A complication of swine flu
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315585907 aan.sagepub.com
Ajit Kumar Padhy, Anubhav Gupta, Palash Aiyer, Narender Singh Jhajhria, Vijay Grover and Vijay Kumar Gupta
Abstract The occurrence of spontaneous pneumomediastinum in swine flu, or H1N1 influenza A infection, is a rare phenomenon and only few cases have been reported in children. We describe a case of spontaneous pneumomediastinum in adult infected with swine flu.
Keywords Adult, Influenza A virus, H1N1 subtype, Influenza, human, Mediastinal emphysema
Introduction The occurrence of spontaneous pneumomediastinum (SPM) in swine flu, or H1N1 influenza A infection, is a rare phenomenon and only few cases of SPM have been reported in children. To the best of our knowledge, this is the first report of a case of SPM in an adult infected with swine flu.
Case report A 32-year-old man presented to our institute with history of cough, fever, and dyspnea for 5 days. Examination revealed tachypnea, bilateral rhonchi, and diminished vesicular sounds in the bilateral lower zone. Palpable crepitations were present over the neck and chest wall. A nasal swab was positive for H1N1 infection. A chest radiograph (Figure 1) indicated surgical emphysema in the neck and chest wall, as well as bilateral pleural effusions. Contrast-enhanced computed tomography of the chest revealed surgical emphysema in the myofascial planes of neck and chest wall, with pneumomediastinum, bilateral pleural effusions, and bilateral lower lobe consolidation (Figure 2). Spontaneous resolution of pneumomediastinum, subcutaneous emphysema, and pneumonia occurred after treatment with oseltamivir phosphate, cephalosporins, and bilateral intercostal tube drainage.
Discussion The clinical presentation of swine flu varies from a mild self-limiting febrile respiratory tract infection to
dreaded complications such as secondary bacterial pneumonia, pneumomediastinum, and respiratory failure.1 SPM as a complication of swine flu was first described in one Mexican patient,2 and another two patients in Japan.3 Three cases of SPM related to pandemic H1N1 influenza associated with air leak syndrome were reported in Ottawa, Canada.4 In India, only one case has been reported so far,5 but all of the cases reported so far belong to pediatric population (Table 1). To the best of our knowledge, our case is the first adult who developed SPM in swine flu. SPM is typically triggered by respiratory infection and inflammation. Any rise in intrathoracic pressure causes rupture of alveoli or pneumatoceles near the mediastinal pleura, leading to air dissection along the bronchovascular sheath, because air tends to follow the path of least resistance, which in turn, causes pulmonary interstitial emphysema and pneumomediastinum. In addition, air leak through the interstitium into the hilum and the neck along the deep fascial planes and subsequently, the subcutaneous planes, leads to subcutaneous emphysema in the neck and Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research and Dr Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India Corresponding author: Ajit Kumar Padhy, Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research and Dr Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, Delhi 110001, India. Email: drajitpadhy@gmail. com
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 26, 2015
XML Template (2015) [30.4.2015–10:22am] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/150063/APPFile/SG-AANJ150063.3d
(AAN)
[1–3] [PREPRINTER stage]
2
Asian Cardiovascular & Thoracic Annals 0(0)
Figure 1. Radiographs of neck and chest showing subcutaneous emphysema with bilateral pleural effusion (arrows).
Figure 2. Computed tomography demonstrating subcutaneous emphysema in the myofascial planes of the neck and thorax with pneumomediastinum.
chest wall.6 In severe pneumomediastinum, the trapped air can cause airway obstruction or impingement on venous return by a tamponade effect.6 SPM should be suspected in the presence of subcutaneous emphysema in the neck and chest wall region. SPM may be missed
because of its subtle clinical manifestations such as cough, dyspnea, neck pain, chest pain, and odynophagia.6 The diagnosis is confirmed by imaging. Although plain radiographic findings including air streaks outlining the mediastinal structures, especially around the
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 26, 2015
XML Template (2015) [30.4.2015–10:22am] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/150063/APPFile/SG-AANJ150063.3d
(AAN)
[1–3] [PREPRINTER stage]
Padhy et al.
3
Table 1. Details of patients with spontaneous pneumomediastinum in swine flu in previous reports. Author
Year
Dawood2 Hasegawa3
2009 2010
Udupa4
2011
Patra5
2011
Age (years)/Sex Not reported 6/F 8/M 9/F 3/M 7/F
Clinical presentation
Treatment
Outcome
SPM Fever, respiratory distress, SPM Fever, chest pain, dyspnea, SPM Cough, neck swelling, diarrhoea, SPM Fever, cough, neck swelling, SPM Fever, respiratory distress, skin rash, SPM
Not reported Antiviral, bronchodilators Antiviral, bronchodilator Antiviral, bronchodilator, antibiotics Antiviral, bronchodilators, antibiotics Antiviral, antibiotics, tracheostomy
Not reported Recovered Recovered Recovered Recovered Died
SPM: spontaneous pneumomediastinum.
tracheostomy is lifesaving in these cases (Figure 3),5,6 which can be performed at the bedside under local anesthesia. SPM is a very unusual complication of swine flu and should be looked for in the presence of subcutaneous emphysema. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References Figure 3. Cervical mediastinotomy: the cervicomediastinal fascial continuity is entered by a suprasternal transverse incision below the level of cricoids cartilage. The anterior surface of the trachea is reached by retracting the sternohyoid and sternothyroid muscles and dissecting the pretracheal layer of the deep cervical fascia. Further down, the retrovascular plane is entered by finger dissection, passing first behind the innominate vessels (IV), aortic arch, and pulmonary artery (PA), and then down below the level of carina and along both sides of the trachea and main bronchi for approximately 2 cm.
cardiac landmarks, are diagnostic, computed tomography has greater sensitivity for the detection of pneumomediastinum and is considered the gold standard for diagnosis.6 SPM usually resolves within a few days with supportive care which includes analgesia, rest, and treatment of the underlying medical condition.6 Surgical intervention has rarely been described in pneumomediastinum; its use is reserved for pneumomediastinum leading to marked cardiorespiratory compromise. Cervical mediastinotomy with or without
1. Soto-Abraham MV, Soriano-Rosas J, Dı´ az-Quin˜o´nez A, et al. Pathological changes associated with the 2009 H1N1 virus. N Engl J Med 2009; 361: 2001–2003. 2. Dawood FS, Jain S, Finelli L, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med 2009; 360: 2605–2615. 3. Hasegawa M, Hashimoto K, Morozumi M, Ubukata K, Takahashi T and Inamo Y. Spontaneous pneumomediastinum complicating pneumonia in children infected with 2009 pandemic influenza A (H1N1) virus. Clin Microbiol Infect 2010; 16: 195–199. 4. Udupa S, Hameed T and Kovesi T. Pneumomediastinum and subcutaneous emphysema associated with pandemic (H1N1) influenza in three children. CMAJ 2011; 183: 202–212. 5. Patra PK, Nayak US and Sushma TS. Spontaneous pneumomediastinum in H1N1 infection. Indian Pediatr 2011; 48: 976–977. 6. Caceres M, Ali SZ, Braud R, Weiman D and Garrett HE Jr. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg 2008; 86: 962–966.
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 26, 2015
![[Pneumorrhachis and spontaneous pneumomediastinum, asthmatic rare complication].](/assets/img/hold.png)
