An adolescent with chest pain.

To the Editor: Chest pain in adolescents and young adults is a common presentation in the emergency department. Chest pain in children is rarely caused by organic conditions; however, it requires careful evaluation as many noncardiac conditions may present with chest pain. This report describes the presence of spontaneous pneumomediastinum with minimal exertion in an adolescent.

An 18-year-old male was brought to the Emergency Department (ED) with acute chest pain. He described his pain as sharp, diffuse and nonradiating. The pain intensity was reported to be 7 on a pain scale of 1 to 10. His pain was aggravated with inspiration, and alleviated by sitting up. He had no nausea, vomiting, headache or shortness of breath. On further questioning, he complained of mild sore throat but no dysphagia. He also denied neck or abdominal pain. There was no hoarseness or pain on phonation.

His symptoms started two days before his presentation to the ED. He denied any recent trauma, but did state he played rugby two days prior, and Frisbee one day before his visit. He also reported wrestling and weight lifting; the last time was approximately a week before the visit. He denied smoking and use of recreational drugs. He was known to have attention deficit hyperactivity disorder (ADHD) and Tourette syndrome and was taking methylphenidate. He had no history of asthma.

At arrival he was alert and active and not in distress. His vital signs revealed a temperature of 97.6[degrees]F, heart rate 65 beats/min, respiration 16 breaths/min, blood pressure 143/76 mm Hg and oxygen saturation of 99%. His neck was supple with palpable crepitations on both sides of his neck, but more on the right. He was talking normally and there was no drooling. He had good air entry on both sides of his chest with symmetrical breath sounds and without any retractions. Normal heart sounds were present. Hamman sign was present. His abdomen was soft and nontender. There was no organomegaly. Bowel sounds were normal. The rest of his physical examination was unremarkable.

His laboratory evaluation, which consisted of cardiac profile, electrolytes with liver function tests, and CBC with differential, were normal. The patient had a normal electrocardiogram. His urine toxicology was also negative. A x-ray of the chest and neck showed large pneumomediastinum, questionable tiny pneumopericardium and subcutaneous emphysema of the neck. A CT scan of chest further delineated subcutaneous emphysema of the neck soft tissue, pneumomediastinum and pneumopericardium.

Spontaneous pneumomediastinum is a relatively uncommon cause of pediatric chest pain. (1) It is defined as a nontraumatic mediastinal air leak without any apparent precipitating underlying cause. (2) In fact, these events are not truly spontaneous but are related to an acute increase in intra-alveolar pressure due to cough, sneezing, vomiting or Valsava maneuver. (3) Although uncommon, spontaneous pneumomediastinum can occur in association with athletic participation. The most common identifiable precipitating factors include illicit drug abuse, noncontact physical sporting activity (weight lifting and tennis) and asthma. (4)

Chest pain and dyspnea are the common presenting symptoms of spontaneous pneumomediastinum. Most cases can be diagnosed by physical examination and chest roentgenogram. The most consistent finding on physical examination is subcutaneous emphysema or a "Hamman crunch." This sign consists of a crunch-like sound over the left hemithorax anteriorly. It is generally reported in approximately 50% of patients with spontaneous pneumomediastinum. The chest x-ray usually confirms the diagnosis and shows streaky gas densities along the fascial planes of the mediastinum.

Air in the subcutaneous tissues may result either from a break in the continuity of the respiratory tract or from a perforation in the gastrointestinal tract. After the exclusion of these serious conditions, primary spontaneous pneumomediastinum can usually be managed expectantly with careful observation. (5) The natural course of simple spontaneous pneumomediastinum is self-limiting and generally resolves spontaneously within 3 to 10 days.

This case illustrates the association of a minor precipitating factor with pneumomediastinum. Emergency physicians should consider the diagnosis of spontaneous pneumomediastinum in the presence of risk factors when evaluating children and adolescents with chest pain.

Krishan Kumar, MD

Nassau University Medical Center 

East Meadow, NY

References

1. Abolnik I, Lossos IS, Breuer R. Spontaneous pneumomediastinum. A report of 25 cases. Chest 1991;100:93-95.

2. Gardikis S, Tsalkidis A, Limas C. Spontaneous pneumomediastinum: is a chest X-ray sufficient? Minerva Pediatr 2003;55:293-296.

3. Gerazounis M, Athanassiadi K, Kalantzi N. Spontaneous pneumomediastinum: a rare benign entity. J Thorac Cardiovasc Surg 2003;126:774-776.

4. Koullias GJ, Korkolis DP, Wang XJ, et al. Current assessment and management of spontaneous pneumomediastinum: experience in 24 adult patients. Eur J Cardiothorac Surg 2004;25:852-855.

5. Weissberg D. Spontaneous mediastinal emphysema. Eur J Cardiothorac Surg 2004;26:885-888.