Case Report

Spontaneous Pneumomediastinum due to Achalasia: A Case Report

Authors: Savio Reddymasu, MD, Fathali Borhan-Manesh, MD, Paul A. Jordan, MD

Abstract

Spontaneous pneumomediastinum (SPM) is a rare and benign clinical entity characterized by free air around mediastinal structures. Precipitating factors include violent cough, asthma, inhalational drugs, labor and exercise. We report a case of SPM due to achalasia which to the best of our knowledge, has never been reported. In achalasia, Valsalva maneuver might accompany severe vomiting. This causes alveolar rupture due to elevated intrabronchial and intra-alveolar pressure. Air tracks along the mediastinal spaces cause SPM. In our patient, there was no evidence of esophageal perforation. Tension pneumomediastinum and pneumothorax are complications of SPM.


Key Points


* Spontaneous pneumomediastinum (SPM) is defined as free air around mediastinal structures without any obvious etiology.


* SPM has not been reported with achalasia.


* SPM is common in thin, young individuals presenting with chest pain.


* SPM occurs due to tracking of air along mediastinal spaces following alveolar rupture, due to any condition which can cause Valsalva maneuver.


* Tension pneumomediastinum and pneumothorax are possible complications of SPM.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Hamman L. Spontaneous mediastinal emphysema. Bull Johns Hopkins 1939;64:1–21.
 
2. Panacek EA, Singer AJ, Sherman BW, et al. Spontaneous pneumomediastinum: clinical and natural history. Ann Emerg Med 1992;21:67–72.
 
3. Weathers LS, Brooks WG, DeClue TJ. Spontaneous pneumomediastinum in a patient with ketoacidosis: a potentially hidden complication. South Med J 1995;88:483–485.
 
4. Kim KI, Lee JW, Lee MK, et al. Polypoid endobronchial Hodgkin's disease with pneumomediastinum.Br J Radiol 1999;72:392–394.
 
5. Sikdar T, MacVivar D, Husband JE. Pneumomediastinum complicating bleomycin related lung damage. Br J Radiol 1998;71:1202–1204.
 
6. Partridge RA, Coley A, Bowie R, et al. Sports-related pneumothorax. Ann Emerg Med 1997;30:539–541.
 
7. Morgan EJ, Henderson DA. Pneumomediastinum as a complication of athletic competition. Thorax1981;36:155–156.
 
8. Bittinger M, Wienbeck M. Pneumatic dilation in achalasia. Can J Gastroenterol 2001;15:195–199.
 
9. Weusten BL, Samsom M, Smout AJ. Pneumothorax complicating botulinum toxin injection in the body of a dilated oesophagus in achalasia. Eur J Gastroenterol Hepatol 2003;15:561–564.
 
10. Macklin MT, Macklin CC. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory disease and other conditions; an interpretation of the clinical literature in the light of laboratory experiment. Medicine 1944;23:281–358.
 
11. Freixinet J, Garcia F, Rodriguez PM, et al. Spontaneous pneumomediastinum long-term follow-up.Respir Med 2005;99:1160–1163.
 
12. Jougon JB, Ballester M, Delcambre F, et al. Assessment of spontaneous pneumomediastinum: experience with 12 patients. Ann Thorac Surg 2003;75:1711–1714.
 
13. Abolnik I, Lossos IS, Breuer R. Spontaneous pneumomediastinum: a report of 25 cases. Chest1991;100:93–95.
 
14. Jungbluth T, Bouchard R, Kujath P, et al. Complicated course of oesophageal perforations because of fungal infections. Mycoses 2005;48 (Suppl 1):41–45.
 
15. Tran HA, Vincent JM, Slavin MA, et al. Esophageal perforation secondary to angio-invasive Candida glabrata following hemopoietic stem cell transplantation. Clin Microbiol Infect 2003;9:1215–1218.
 
16. Koulmann P, Perez JP, Bonnet PM, et al. Candida albicans induced empyema: mode of revelation of a spontaneous oesophageal disrupture. Ann Fr Anesth Reanim 2003;22:470–473.
 
17. Ganatra JV, Bostwick HE, Medow MS, et al. Candida esophagitis in a child with achalasia. J Pediatr Gastroenterol Nutr 1996;22:330–333.
 
18. Hendel L, Svejgaard E, Walsoe I, et al. Esophageal candidosis in progressive systemic sclerosis: occurrence, significance and treatment with fluconazole. Scand J Gastroenterol 1988;23:1182–1186.