Pneumomediastinum and epidural pneumatosis after inhalation of "Ectasy"

Traumatic pneumorrhachis associated with cerebral fluid leakage evaluated with magnetic resonance myelography

Attention should be paid to cerebrospinal fluid leakage in patients with pneumorrhachis associated with vertebral body trauma. If pneumorrhachis is detected, further imaging investigation and bed rest should be considered as appropriate.

Spontaneous pneumorrhachis with pneumomediastinum, scrotal emphysema, and extensive subcutaneous emphysema in a patient with pneumonia: A case report and literature review

BACKGROUND

Spontaneous pneumorrhachis with pneumomediastinum, scrotal emphysema, and extensive subcutaneous emphysema caused by acute pneumonia are rarely observed in clinical practice.

CASE PRESENTATION

Herein, we report a case of a 12-year-old boy with spontaneous pneumorrhachis with pneumomediastinum, scrotal emphysema, and extensive subcutaneous emphysema caused by a severe cough due to mycoplasma pneumonia. This patient neither received invasive or noninvasive ventilator treatment nor surgical treatment before the onset of the disease. After treatment, the patient recovered smoothly and was discharged from the hospital.

LITERATURE REVIEW

We reviewed all cases of spontaneous pneumorrhachis in children and adolescents between 1988 and 2022 in the PubMed database. Twenty-seven cases met our inclusion criteria, and the data on demographic information, triggers, comorbidities, symptoms, imaging findings, treatment, and prognosis were extracted and analyzed.

CONCLUSION

Although spontaneous pneumorrhachis is a rare condition, it has been reported in children. Computed tomography scanning is the gold standard for its detection. Spontaneous pneumorrhachis is typically a benign disease. This condition usually does not require any special treatment and should be monitored as common types of air leaks, such as pneumothorax and pneumomediastinum.

Rare Case of Spontaneous Pneumorrhachis in a Young Male with COVID-19

Here we present a rare case of spontaneous pneumomediastinum complicated with pneumorrhachis (PR) in a young man who is a known case of carcinoma rectosigmoid region. Our young male was diagnosed with novel coronavirus disease 2019 (COVID-19) and remained asymptomatic for any respiratory complaints. Though an association of pneumomediastinum has been reported in COVID 19 patients, to the best of our knowledge, this is the first report of PR in a COVID-19 oncological case. The role of a radiologist is to identify this condition as cases reported earlier may have serious neurological consequences. Pursuing the cause can be a diagnostic challenge but it reaps the clinical benefit in the appropriate management.

Traumatic pneumorrhachis: systematic review and an illustrative case

Pneumorrhachis (PR) refers to free air in the spinal canal. We aim to describe a case report and conduct a systematic review focused on the clinical presentation, diagnosis, and management of traumatic PR. We conducted a language-restricted PubMed, SciELO, Scopus, and Ovid database search for traumatic PR cases published till June 2019. Categorical variables were assessed by Fisher's exact test. In addition to our reported index case, there were 82 articles (96 individual cases) eligible for meta-analysis according to our inclusion/exclusion criteria. Eighty per cent of patients had blunt trauma, while 17% had penetrating injuries. Thirty-four per cent of cases were extradural PR, 21% intradural PR, and unreported PR type in 43%. Nine per cent of patients presented with symptoms directly attributed to PR: sensory radiculopathy (2%), motor radiculopathy (1%), and myelopathy (6%). CT had a 100% sensitivity for diagnosing PR, MRI 60%, and plain radiograph 48%. Concurrent injuries reported include pneumocephalus (42%), pneumothorax (36%), spine fracture (27%), skull fracture (27%), pneumomediastinum (24%), and cerebrospinal fluid leak (14%). PR was managed conservatively in every case, with spontaneous resolution in 96% on follow-up (median = 10 days). Prophylactic antibiotics for meningitis were given in 13% PR cases, but there was no association with the incidence of meningitis (overall incidence: 3%; prophylaxis group (0%) vs non-prophylaxis group (4%) (p = 1)). Occasionally, traumatic PR may present with radiculopathy or myelopathy. Traumatic PR is almost always associated with further air distributions and/or underlying injuries. There is insufficient evidence to support the use of prophylactic antibiotic in preventing meningitis in traumatic PR patients.

Rapid disappearance of pneumorrhachis after chest tube placement

Introduction

We present a rare case of traumatic pneumorrhachis with the combination of hemothorax which resolved rapidly after insertion of a chest tube.

Case presentation

A 55 year old male was admitted to our emergency department after falling from a ladder. His general condition was well, GCS was 15 with no motor deficits. On his spinal CT a fracture on multiple ribs leading to right sided hemothorax was observed with air in the T6-T8 spinal canal. A chest tube was placed and as he did not have any neurological deficits surgical intervention to the pneumorrhachis was not considered. On the next day's a follow-up CT the air in the spinal canal was reduced and on the 5th day resolved completely.

Conclusion

Traumatic pneumorrhachis is a rare phenomenon and is not fully understood how the air from the posterior mediastinal wall can spread to the epidural or subarachnoid space. One hypothesis for subarachnoid air is that the high pressure air from a pneumothorax or pneumomediastinum pushes in a one-valve mechanism through the fascial layers of the posterior mediastinum through the neural foramina into the spinal canal. In our case, after the insertion of the chest tube the air in the subarachnoid space resolved and the patient's tingling sensation on his legs disappeared. We believe that the negative pressure of the chest tube did a somehow reverse effect of the air flow back from the spinal canal into the chest tube which has not been reported in the literature before.

Proportion and Clinical Relevance of Intraspinal Air in Patients With Pneumomediastinum

OBJECTIVE

The purposes of this study were to determine the incidence of pneumorrhachis among patients with pneumomediastinum, determine whether its proportion correlates with the extent of pneumomediastinum, and ascertain its clinical relevance.

MATERIALS AND METHODS

The radiologic database was searched for CT reports between January 2009 and September 2013 containing the term "pneumomediastinum" or "mediastinal air." Scans were examined for pneumomediastinum, pneumorrhachis, pneumothorax, sternotomy, and distribution of pneumomediastinum. The age and sex of the patient and probable cause of the abnormality were recorded. Cases that might have had another cause were excluded.

RESULTS

The search yielded 422 CT scans. Among these, 242 instances of pneumomediastinum in 241 patients were found. Fifteen of these patients had pneumorrhachis. One was excluded because of recent traumatic spinal penetration. There was no significant difference in age or sex between patients with and those without pneumorrhachis. After application of the exclusion criteria, there were 14 cases of pneumorrhachis, yielding a proportion of 5.8%. Pneumorrhachis was observed more frequently in cases of the most severe grade (grade C) of pneumomediastinum; however, that relationship was not statistically significant (11 cases [8.2%]; p = 0.304). Pneumorrhachis was found significantly more frequently in patients with distribution of air in all three mediastinal compartments (13 cases, 16.2%, p < 0.001). Pneumorrhachis was overrepresented among subjects with spontaneous compared with those with secondary pneumomediastinum, although the trend did not reach statistical significance.

CONCLUSION

Pneumorrhachis was present in 5.8% of patients. It is significantly more common in patients with the broadest distributions of mediastinal air and nonsignificantly more common in association with spontaneous as opposed to secondary pneumomediastinum. Pneumorrhachis in patients with pneumomediastinum is a generally benign, self-resolving condition.

Traumatic pneumorrachis after isolated closed head injuries: An up-to-date review

Pneumorrachis (PR) is characterized by the presence of air within the spinal canal. It can be classified descriptively into internal or intradural and external or epidural. The causes of PR can be divided as iatrogenic, nontraumatic and traumatic. In the present study, a comprehensive literature search was conducted to identify all previous cases of PR after an isolate head injury. Two additional cases were also reported. We concluded, that PR after isolated head injuries is a rare but likely an underdiagnosed entity. It is a marker of severe injury and the majority of such patients have a poor outcome. Although, PR is usually asymptomatic and reabsorbs spontaneously, prompt recognition and management of the underlying cause is essential. Therefore, clinicians should maintain a high level of suspicion for serious underlying injury in cases where initial radiological imaging reveals intraspinal air.

Stimulants and the lung : review of literature

Illicit stimulants, such as cocaine, amphetamine, and their derivatives (e.g., "ecstasy"), continue to exact heavy toll on health care in both developed and developing countries. The US Department of Health and Human Service reported over one million illicit drug-related emergency department visits in 2010, which was higher than any of the six previous years. Both inhaled and intravenous forms of these substances of abuse can result in a variety of acute and chronic injuries to practically every part of the respiratory tract, leading potentially to permanent morbidities as well as fatal consequences--including but not limited to nasal septum perforation, pulmonary hypertension, pneumothorax, pneumomediastinum, interstitial lung disease, alveolar hemorrhage, reactive airway disease, pulmonary edema, pulmonary granulomatosis, infections, foreign body aspiration, infections, bronchoconstriction, and thermal injuries. Stimulants are all rapidly absorbed substances that can also significantly alter the patient's systemic acid-base balance and central nervous system, thereby leading to further respiratory compromise. Mounting evidence in the past decade has demonstrated that adulterants coinhaled with these substances (e.g., levamisole) and the metabolites of these substances (e.g., cocaethylene) are associated with specific forms of systemic and respiratory complications as well. Recent studies have also demonstrated the effects of stimulants on autoimmune-mediated injuries of the respiratory tract, such as cocaine-induced midline destructive lesions. A persistent challenge to studies involving stimulant-associated respiratory toxidromes is the high prevalence of concomitant usage of various substances by drug abusers, including tobacco smoking. Now more than ever, health care providers must be familiar with the multitude of respiratory toxidromes as well as the diverse pathophysiology related to commonly abused stimulants to provide timely diagnosis and effective treatment.

Asymptomatic pneumomediastinum resulting from air in the epidural space -a case report-

There are no reports regarding pneumomediastinum caused by thoracic epidural block complications. We believe that it is possible to experience an occurrence of pneumomediastinum caused by air in the epidural space after performing a thoracic epidural block using the loss of resistance (LOR) technique with air. We report a witnessed case where pneumomediastinum appeared after a thoracic epidural block. Pneumorrrhachis, paravertebral muscle emphysema, and pneumomediastinum were diagnosed by Positron Emission Tomography-Computed Tomography. Although extremely rare, pneumomediastinum can be caused by an epidural block using LOR technique with air. In order to avoid the above danger, the use of saline or very minimal amount of air is required during a careful LOR technique.

Two cases of spontaneous epidural emphysema during asthmatic attack

Two cases of spontaneous epidural emphysema that occurred during asthmatic attacks in a 13-year-old and a 15-year-old are reported here. Epidural emphysema was diagnosed in both cases by using computed tomography (CT), and in 1 case by using magnetic resonance imaging (MRI). Neither patient had neurological findings. Both patients were discharged with no respiratory difficulties. It is generally believed that a diagnosis of epidural emphysema can only be made on CT. In this report, MRI was used to make the diagnosis of subdural emphysema, and it demonstrated that the air was localized within the epidural fat.

Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment

BACKGROUND CONTEXT

Traumatic pneumorrhachis (PR) is a rare entity, consisting of air within the spinal canal. It can be classified as epidural or subarachnoid, identifying the anatomical space where the air is located, and is associated with different etiologies, pathology, and treatments.

PURPOSE

To conduct a systematic review of the scientific literature focused on the etiology, pathomechanism, diagnosis, and treatment of PR, and to report a case of an asymptomatic epidural type.

STUDY DESIGN

International medical literature has been reviewed systematically for the term "traumatic pneumorrhachis" and appropriate related subject headings, such as traumatic intraspinal air, traumatic intraspinal pneumocele, traumatic spinal pneumatosis, traumatic spinal emphysema, traumatic aerorachia, traumatic pneumosaccus, and traumatic air myelogram. All cases that were identified were evaluated concerning their etiology, pathomechanism, and possible complications.

SAMPLES

Studies that included one of the aforementioned terms in their titles.

METHODS

A systematic review was performed to identify, evaluate, and summarize the literature related to the term "traumatic pneumorrhachis" and related headings. Furthermore, we report a rare case of an asymptomatic epidural PR extending to the cervical and thoracic spinal canal. We present the current data regarding the etiology, pathomechanism, diagnosis, and treatment modalities of patients with PR.

RESULTS

The literature review included 37 related articles that reported 44 cases of traumatic PR. Only isolated case reports and series of no more than three cases were found. In 21 cases, the air was located in the epidural space, and in 23 cases, it was in the subarachnoid space. Most of the cases were localized to a specific spinal region. However, eight cases extending to more than one spinal region have been reported.

CONCLUSIONS

Traumatic PR is an asymptomatic rare clinical entity and often is underdiagnosed. It usually resolves by itself without specific treatment. We stress the significance of this information to trauma specialists, so that they may better differentiate between epidural and subarachnoid PR. This is of great significance because subarachnoid PR is a marker of severe injury. The management of traumatic PR has to be individualized and frequently requires multidisciplinary treatment, involving head, chest, and/or abdomen intervention.

Epidural pneumatosis of the cervicothoracic spine associated with transient upper motor neuron findings complicating Haemophilus influenzae pharyngitis, bronchitis, and mediastinitis

BACKGROUND

Epidural pneumatosis and pneumomediastinum are rare findings. Reports in children are exceedingly rare. Abnormal neurologic findings have yet to be reported.

METHODS

We report on the case of a 7-year-old girl who was diagnosed with epidural pneumatosis with signs of neurologic compression in the setting of Haemophilus influenzae upper and lower respiratory infection. After urgent direct laryngoscopy, bronchoscopy, esophagoscopy, and pharyngeal biopsy was carried out, CT scan of the chest revealed extensive pneumomediastinum tracking along vessels throughout the neck and chest in addition to epidural pneumatosis from C6 to T5. Upper motor neuron findings were present. Broad spectrum antibiotics were administered, and interval neurologic examination and repeat CT scans showed resolution of abnormal neurologic exam in addition to epidural pneumatosis dissipation.

RESULTS

Rapid clinical improvement was noted on broad spectrum intravenous antibiotics with extubation on postoperative day one. She was discharged home on oral augmentin on postoperative day 4 with intact neurologic examination. At 11 month follow-up, she remained symptom-free with normal neurologic examination and unremarkable cervical and thoracic spine radiographs.

CONCLUSION

Resolution of clinical and radiographic findings is possible with conservative treatment.

LEVEL OF EVIDENCE

IV.

Air within the spinal canal in spontaneous pneumomediastinum

Spontaneous pneumomediastinum is an uncommon benign condition that is occasionally associated with air within the spinal canal. We describe a further case in a 14-year-old girl and suggest a classification system based on a detailed review of the previous literature. Forty-eight patients with spontaneous pneumomediastinum and intraspinal air accumulation (36 men and 12 women, age range 4-72 years, median age 18 years) were grouped into those with underlying lung disease (n = 13), those with other underlying etiologic factors (n = 22), and those arising spontaneously (n = 13). Neurologic symptoms or signs were noted in one case. The remaining cases were successfully managed conservatively. In spontaneous pneumomediastinum, accumulation of air within the spinal canal is self-limiting and benign. The same management is advised in spontaneous pneumomediastinum with and without intraspinal air accumulation.

Ecstasy-associated pneumomediastinum

INTRODUCTION

Ecstasy, also known as MDMA (3,4, methylenedioxymethamphetamine), is a popular illicit party drug amongst young adults. The drug induces a state of euphoria secondary to its stimulant activity in the central nervous system.

PATIENTS AND METHODS

A database review at two major inner city hospitals was undertaken to identify patients presenting with pneumomediastinum and their charts reviewed. A Medline review of all reported cases of pneumomediastinum associated with ecstasy abuse was undertaken.

RESULTS

A total of 56 patients presenting with pneumomediastinum were identified over a 5-year period. Review of the charts revealed a history of ecstasy use in the hours prior to presentation in six of these patients, representing the largest series reported to date.

CONCLUSIONS

Review of previously reported cases reveals the likely mechanism is due to Valsalva manoeuvre during periods of extreme physical exertion, and not a direct pharmacological effect of the drug.

Pathogenesis, diagnosis and management of pneumorrhachis

Pneumorrhachis (PR), the presence of intraspinal air, is an exceptional but eminent radiographic finding, accompanied by different aetiologies and possible pathways of air entry into the spinal canal. By reviewing the literature and analysing a personal case of traumatic cervical PR after head injury, we present current data regarding the pathoanatomy, clinical and radiological presentation, diagnosis and differential diagnosis and treatment modalities of patients with PR and associated pathologies to highlight this uncommon phenomenon and outline aetiology-based guidelines for the practical management of PR. Air within the spinal canal can be divided into primary and secondary PR, descriptively classified into extra- or intradural PR and aetiologically subsumed into iatrogenic, traumatic and nontraumatic PR. Intraspinal air is usually found isolated not only in the cervical, thoracic and, less frequently, the lumbosacral regions but can also be located in the entire spinal canal. PR is almost exceptional associated with further air distributions in the body. The pathogenesis and aetiologies of PR are multifold and can be a diagnostic challenge. The diagnostic procedure should include spinal CT, the imaging tool of choice. PR has to be differentiated from free intraspinal gas collections and the coexistence of air and gas within the spinal canal has to be considered differential diagnostically. PR usually represents an asymptomatic epiphenomenon but can also be symptomatic by itself as well as by its underlying pathology. The latter, although often severe, might be concealed and has to be examined carefully to enable adequate patient treatment. The management of PR has to be individualized and frequently requires a multidisciplinary regime.

[Drug addiction and cardiovascular pathologies]

Drug addiction which entails cardiovascular risks unknown or misknown to physicians, currently involves an increasing number of miscellaneous drugs, existing in manifold forms. There appears to be no bounds on the way of intake. All territories of the body may be affected with more or less severity. In young people, the cardiac, coronary, cerebral and peripheral vascular systems are generally involved. Two illicit drugs, cannabis and cocaine, showing a permanent increase in misuse, prevail. This drug addiction comes along with intercurrent pathologies which have their own vascular toxicity, especially HIV infection. Moreover, the advent of new illicit substances emphasizes the complexity of the clinical presentations. These complex situations have a real social and medical impact. We are currently in a phase of permanently increasing risk of cardiovascular complications. The pathophysiological mechanisms involved are intertwined and complicated by the frequent association of polytoxicomania or by the effects excipients added to these drugs: direct vascular toxicity, angeitis, arterial and venous thrombosis. Arsenic, a common component of these drugs, is also found in cigarettes; arsenic toxicity mainly affects the lower limbs. Treatment of these complications is non-specific; the ideal solution being weaning which, unfortunately in this peculiar population of patients, may entail serious complications due to the misuse of substitution products.