Factitious subcutaneous emphysema of an extremity

Life events and quality of life in female patients with dermatitis artefacta: a comparative study with siblings and controls

BACKGROUND

If the severity of dermatitis artefacta (DA) is accepted by most authors, few published studies have sought to clarify its etiology and impact. It is in this context that this work aimed to compare Life Events (LE) and quality of life (QoL) scores in patients with DA, in their siblings and in control patients with other chronic dermatological diseases.

METHODS

This is a descriptive and comparative cross-sectional study carried out in the dermatology department of Farhat Hached hospital in Sousse, Tunisia. Thirty female patients diagnosed with DA according to DSM-IV criteria were retrospectively recruited. For each patient with DA, one of her sisters, the closest in age, was enrolled in the siblings group. The control group consisted of thirty female patients with other chronic dermatological diseases, matched with DA patients for age and duration of disease progression. Assessment was based on Paykel inventory for LE and on SF-36 for QoL.

RESULTS

Compared to both control groups, DA patients reported more LE with more objective negative impact of these events and had a lower score and more often impaired mean global score of QoL.

CONCLUSIONS

LE would have a role in the pathogenesis of DA which seems to alter the QoL of patients. These results could help to improve the understanding of DA and incite clinicians to focus not only on the diagnosis and treatment of DA but also on the impact of this disease.

Misdiagnosed pneumothorax interpreted as necrotizing fasciitis of the chest wall: case report of a potentially preventable death

Background

Subcutaneous emphysema is an uncommon clinical finding associated both with benign sources and potentially deadly necrotizing infections. Wide ranges of causes exist including trauma, iatrogenic injuries, factitious disorders and necrotizing infections.

Case presentation

A 49-year old male presented to the emergency room with extensive subcutaneous emphysema following blunt trauma. The orthopaedic surgery service was consulted for treatment of suspected necrotizing fasciitis due to his subcutaneous emphysema. A careful patient history and physical examination correlated with laboratory and radiographic findings revealed rib fractures and a long-standing, undiagnosed pneumothorax as the cause for emphysema. Treatment of the underlying condition with chest tubes led to eventual resolution of the emphysema, though multisystem organ failure ultimately resulted in patient death.

Conclusion

This case illustrates the importance of rapidly and appropriately evaluating trauma patients, and in this case specifically diagnosing and treating the underlying cause of subcutaneous emphysema. The late diagnosis of pneumothorax resulted in delayed definitive treatment, which may have contributed to the patient’s ultimate demise. In acute and sub-acute trauma situations a high level of suspicion for life threatening injuries must be maintained. Decision making for initial treatment should be based on the basic tenants of Advanced Trauma Life Support to primarily address these injuries and help prevent further disability or death.

[Benign subcutaneous emphysema after nail penetration. Case report and important differential diagnoses]

Crepitus under the skin after penetrating injuries: harmless benign subcutaneous emphysema or life-threatening infection with gas-producing bacteria (gas gangrene because of Clostridium perfringens, crepitating cellulitis because of anaerobic Streptococcus or other coliforme bacteria)? We report a case of a 74-year-old male who developed massive crepitation of the left upper extremity and the lateral thoracic wall and mediastinal emphysema after sustaining a laceration of the left thumb and forefinger from a nail. Because there was the suspicion of gas gangrene we performed generous skin incisions of the ventral and dorsal part of the hand, the forearm and upper arm and open wound treatment. A triple antibiotic therapy was initiated. Due to fast regression of the subcutaneous emphysema and the mediastinal emphysema, continuing lack of symptoms, negative smear test results from the beginning and low infection parameters in the blood all wounds could be closed 9 days after primary surgery. The suspicion of gas gangrene was not confirmed so the diagnosis of benign subcutaneous emphysema was made.

Self-infliction of faked gunshot wounds in absence of overt psychopathology

Distinguishing deliberate self-inflicted body damage from assault represents a challenge to the forensic expert. Identifying a wound as self-inflicted can be particularly difficult in emergency room situations. We present the case of an individual who self-inflicted three bullet wounds, allegedly related to a shooting incident. This individual was lacking any overt psychopathology. When confronted with the facts, he confessed and explained his motivation. It is known that self-mutilation behavior can be related to particular, well systematized psychiatric disorders. However, in the absence of such a diagnosis, every suspicious wound should be carefully considered by the forensic expert as potentially self-inflicted with the intent by the "victim" of obtaining secondary gains.

[Intercompartment soft tissue emphysema after arthroscopic meniscus resection. Case report and differential diagnosis]

Soft-tissue emphysema following surgical procedures needs prompt and accurate diagnosis in order not to miss severe infections, such as clostridial myonecrosis and necrotizing fasciitis. We report the case of a 32-year-old patient who developed massive crepitation of the right leg and thoracic wall after knee arthroscopy had been performed a few days earlier. He was readmitted under suspicion of gas gangrene. This could not be ruled out by preoperative examinations as a subacute infection existed in the range of the infrapatellar incision. A mini-arthrotomy was carried out to exclude necrotizing soft tissue infection and to rinse the joint. An intercompartment emphysema could be confirmed intraoperatively. The postoperative course was uneventful. The main differential diagnoses of benign soft Tissue emphysema are summarized and treatment options are recommended.

Recurrent factitious subcutaneous emphysema: report of a complex case in a young woman and a literature review

Subcutaneous emphysema (SE) can be caused by antecedent trauma, surgery, rupture of visceral organs or serious infection from gas-forming microorganisms. Factitious SE is very rare; only about a dozen cases have been reported. Most patients had an underlying psychiatric condition or relevant history. The diagnosis and management of factitious SE are challenging. We report a new case of factitious SE with a very complex clinical course. A 29-year-old woman was seen at consultation for recurrent attacks of painful soft tissue swelling, affecting her chest wall, abdomen and neck over several months. Factitious disease was suspected because of the negative medical history of identifiable visceral perforations or gas-forming infections and the presence of multiple bizarre linear scars on the arm. This was supported by finding multiple recent puncture marks on the neck, chest and upper extremities on close inspection. The patient's history was remarkable for multiple stressful events in her life, frequent job changes, substance abuse and suicide attempts. Psychiatric evaluation revealed adjustment disorder with depression and anxiety, cluster B personality with bipolar II disorder and substance abuse. During the 1-year period, she had 20 visits to our ER for attacks of SE affecting various parts of her body. This case illustrates that self-infliction should be suspected in a patient presenting with medically unexplained recurrent SE and a hollow history, and one should search for puncture marks to support the diagnosis.