Sudden Onset Chest Pain in a Young Man
Case Editor - Victor Kim
Reviewed By Clinical Problems Assembly
Leanne K. Strack, DO
Clinical Instructor and Pulmonary/Critical Care Fellow
The Ohio State University
James M. Oâ€™Brien, MD
Associate Professor of Medicine, Pulmonary/Critical Care Medicine
The Ohio State University
An 18-year-old man presents to the emergency department stating he felt like he “was going to die.” While on break at work, he experienced sudden onset sharp, midsternal chest pain. He had no dyspnea or radiation of the pain. He had not suffered any recent chest trauma but did strike his head on a piece of equipment at work without sequelae. Three days prior to presentation he had cough productive of yellow sputum without fevers or chills. At the time of evaluation, the pain had been present for several hours and was only relieved by narcotic medications.
His past medical history was significant for bipolar disorder, which was controlled without medications. He worked as a stock clerk at a department store. He was a current smoker, 1 pack per day for 2 years, and he gave a history of prior cocaine use, but denied any recent illicit drug usage.
The patient was 69 inches tall and weighed 200 pounds. He was in no acute distress and was afebrile with an oxygen saturation of 99% on room air. There was no crepitus on examination. Lungs were clear to auscultation bilaterally. Cardiac, abdominal, and extremity examinations were unremarkable.
He had a normal complete blood count, electrolyte panel, and creatinine. His cardiac enzymes were negative and electrocardiogram (EKG) was normal except for sinus bradycardia. His toxicology screen was only positive for hydrocodone, which he had been given for pain.
Although all may present with chest pain, the chest radiograph reveals a radiolucent line surrounding the heart, which is seen in patients with pneumomediastinum. The Computed Tomography (CT) scan of the chest also demonstrates air surrounding the mediastinal structures. Our patient suffered from a spontaneous pneumomediastinum, as he did not experience an event that would have precipitated the pneumomediastinum (such as surgery, infection, or chest trauma).
Spontaneous pneumomediastinum is defined as the presence of air in the mediastinum without any precipitating factors, such as infection, trauma, ruptured esophagus or surgery. Also known as mediastinal air or Hamman’s syndrome, spontaneous mediastinum was first described in the literature by Hamman in 1939.
The lack of an infiltrate on the chest radiograph, a normal complete blood count, the absence of physical examination findings and symptoms suggests the patient is not suffering from pneumonia. There is no evidence of a pneumothorax on the chest radiograph or the CT scan. Although the entire ascending aorta is not visualized in the CT scan, there is no evidence of a dissecting ascending aortic aneurysm. A normal EKG and negative set of cardiac enzymes makes acute coronary syndrome less likely of a diagnosis, as well as his young age with the negative results of the toxicology screen.
Spontaneous pneumomediastinum is most commonly seen in young, tall, thin adult males; more than 75% of the cases are in males with a mean age of 20 years (1). However it can also be seen in pregnant or postpartum women and following illicit drug use. Several other predisposing factors exist, including the following: the presence of asthma or other underlying pulmonary disease, performing a Valsalva maneuver (as seen with sneezing, defecating, or vomiting), infection of the upper airways, and intense work of breathing (such as after exercise). It has also been noted to occur after pulmonary function testing and inflating balloons (2).
Hamman’s sign, a dry crackling noise heard during auscultation of the heart (especially systole), is present in few patients with pneumomediastinum. However it is thought to be pathognomonic when present. Auscultation of Hamman’s sign can be accentuated during expiration; especially with the patient is the left lateral decubitus position. Patients with spontaneous pneumomediastinum often present with dyspnea and sudden onset of sharp, midsternal chest pain that is pleuritic in nature and radiates to the back or shoulders. They may also complain of cough, neck pain, odynophagia, dysphonia, back pain, dysphagia, or abdominal pain. Physical examination generally reveals no abnormalities; however subcutaneous emphysema may be present in the neck. A low grade fever may be present, possibly secondary to cytokine release (3).
Although the diagnosis is suspected by history and physical examination, it is confirmed by radiographic studies. Radiolucent lines in the mediastinum extending toward the neck are seen on plain chest radiographs. There may also be presence of air surrounding mediastinal structures such as the aorta, trachea, esophagus, or thymic gland. The “continuous diaphragm sign” is seen on frontal chest radiographs, and is the presence of a connecting line between the right and left hemidiaphragms. “Ring around the artery” may be seen on a lateral chest radiograph and is due to the presence of air surrounding the aorta. A “thymic sail sign” may be visualized on the lateral chest radiograph and is the presence of air that elevating the thymic gland. A CT scan of the chest is considered the gold standard for detection of pneumomediastinum, which can detect even a minimal pneumomediastinum. A CT scan should be obtained if the diagnosis is unclear or if the pneumomediastinum is thought to be secondary to another process. Oral contrast, as well as intravenous contrast, should be used if the clinical presentation supports a possible disruption of the esophagus. When reviewing the CT scan, close attention should be paid to the integrity of the tracheobronchial tree, the presence of an occult pneumothorax, or the extravastation of oral contrast into the mediastinum; all of which support an alternate cause of the pneumomediastinum. MRI does not add benefit over a CT scan.
Treatment of a spontaneous pneumomediastinum is rest, oxygen, and pain control. The patient should also be reassured that complications and recurrence are extremely rare. There is no consensus on criteria for admission to the hospital for observation, however most patients are admitted for a two to five day observation period. (1). Bronchoscopy or esophagogastroduodenoscopy (EGD) should not be performed routinely unless there is suspicion of disruption of the tracheobronchial tree or the esophagus. Antibiotic therapy should be withheld unless esophageal perforation is suspected.
Patients should be advised that recurrence and complications are rare. Follow-up visit with a physician should occur within 1- 2 weeks to assure no recurrence of symptoms. Suggestions to avoid high-risk strenuous activities, playing pneumonic instruments, air travel, and scuba diving have been recommended; however there is no consensus on the length of time for avoidance of these activities. Asthmatic patients should continue good asthma control.
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