March 2023 Medical Image of the Month: Spontaneous Pneumomediastinum as a Complication of Marijuana Smoking Due to Müller's Maneuvers

Figure 1. PA chest radiograph obtained at the time of admission (A) demonstrating gas densities (arrows) along left heart border, left paratracheal stripe, upper mediastinum and neck extending into the right supraclavicular fossa in keeping with pneumomediastinum. Follow-up PA chest radiograph performed just before discharge (B) demonstrates resolution of pneumomediastinum.

Figure 2. Two axial images through the anterior mediastinum obtained from a contrast-enhanced chest CT demonstrating gas densities (arrows) in the mediastinum anterior to the heart and around the esophagus in-keeping with pneumomediastinum.

A 35-year-old woman with a medical history notable for celiac disease, ulcerative colitis, and bipolar disorder presents to the Emergency Department for evaluation of a strange sensation in the chest and neck associated with nausea and vomiting for one day. The patient also reports persistent nausea and markedly decreased oral intake for the last four days. She reported no concomitant symptoms such as shortness of breath, wheezing, fever, or chills. She denies diarrhea or constipation. Socially, she admits to smoking marijuana daily, and alcohol occasionally.

Vital sign shows blood pressure 147/97 mmHg, pulse 92 BPM, temperature 37.3°C, SpO2 96% breathing ambient air. She appears nontoxic and well-nourished, and the lungs are clear to auscultation bilaterally without any wheezes, rales, or rhonchi. The heart examination reveals a regular rate and rhythm, with normal S1 and S2 heart sounds and no murmurs, rubs, or gallops. The abdomen is soft, non-tender, and not distended. Her extremities do not exhibit any clubbing, cyanosis, or edema. CBC and CMP were unremarkable, and the drug screen test was positive for THC. An ECG is obtained (not shown here), which reveals a normal sinus rhythm with a heart rate of 55 beats/min and no ST-segment or T-wave abnormalities. Chest x-ray and CTA chest, CT abdominal with oral contrast were obtained (Figures 1 and 2). Upon further questioning of the patient’s social history, it was discovered that she smokes marijuana daily using water pipes, and while utilizing a water pipe she attempted a full inspiration against a closed mouth and nose, a technique known as the Müller’s maneuver.

Spontaneous pneumomediastinum (SPM) is a rare condition in which air escapes from the lungs and collects in the mediastinum, the space between the lungs. SPM is almost always a benign, self-limited condition. While SPM can be caused by a variety of factors, including coughing, vomiting, and physical trauma, this case report presents a rare instance of SPM caused by marijuana smoking. Spontaneous pneumomediastinum (SPM) was reported in 1939 by Johns Hopkins clinician Louis Hamman for whom the Hamman sign is named. It is defined as free air or gas contained within the mediastinum, which almost originates from the alveolar space or the conducting airways. Many authors distinguish spontaneous pneumomediastinum as a form of pneumomediastinum that is not associated with blunt force or penetrating chest trauma, endobronchial or esophageal procedures, neonatal lung disease, mechanical ventilation, chest surgery, or other invasive procedures.

The mechanism by which marijuana smoking leads to pneumomediastinum is not well understood, but it is thought to involve increased intra-alveolar pressure and alveolar rupture. This can result in the escape of air into the mediastinum, leading to the development of pneumomediastinum. SPM has been associated with the inhalation of drugs such as cocaine, amphetamines, and marijuana (1-4). Attempted inspiration through a closed glottis or Muller’s maneuver results in a drop in intrathoracic pressure, which increases alveolar air volume, causing alveolar distension and rupture which can cause shear damage and air leakage along a bronchovascular bundle into the mediastinum.

The patient, in this case, was a 35-year-old woman with a history of marijuana smoking who presented with symptoms of chest pain, shortness of breath, and dysphagia. Physical examination revealed subcutaneous emphysema and a chest x-ray confirmed the presence of SPM. This case highlights the potential respiratory complications associated with marijuana smoking, which can lead to SPM and other adverse outcomes. While marijuana use is becoming increasingly common and accepted, it is important for healthcare providers to be aware of the potential risks and to educate their patients about the potential consequences of marijuana use. Further research is needed to understand the full extent of the respiratory effects of marijuana smoking and to develop appropriate interventions and treatments.

Mohammad Abdelaziz Mahmoud DO

Doctors Medical Center of Modesto and Emanuel Medical Center

Modesto and Turlock, CA USA

References

1. Weiss ZF, Gore S, Foderaro A. Pneumomediastinum in marijuana users: a retrospective review of 14 cases. BMJ Open Respir Res. 2019 Feb 12;6(1):e000391. [CrossRef] [PubMed]
2. Al-Mufarrej F, Badar J, Gharagozloo F, Tempesta B, Strother E, Margolis M. Spontaneous pneumomediastinum: diagnostic and therapeutic interventions. J Cardiothorac Surg. 2008 Nov 3;3:59. [CrossRef] [PubMed]
3. Puri C, Rhee K, Harish VK, Slack D. Marijuana induced spontaneous pneumomediastinum. J Community Hosp Intern Med Perspect. 2021 Jun 21;11(4):516-517. [CrossRef] [PubMed]
4. Motes A, Laoveeravat P, Thongtan T, Nugent K, Islam S, Islam E. Marijuana use-induced spontaneous pneumomediastinum. Proc (Bayl Univ Med Cent). 2020 Dec 7;34(2):274-275. [CrossRef] [PubMed]

Cite as: Mahmoud MA. March 2023 Medical Image of the Month: Spontaneous Pneumomediastinum as a Complication of Marijuana Smoking Due to Müller's Maneuvers. Southwest J Pulm Crit Care Sleep. 2023;26(3):31-33. doi: https://doi.org/10.13175/swjpccs058-22 PDF 

Medical Image of the Week: Fournier’s Gangrene with a Twist

Figure 1. A: Coronal view of abdominal CT scan showing extensive gas formation from the site of trauma (scrotum) ascending along fascial planes, encompassing abdominal wall and chest wall (arrows). B: Close up view of the scrotum and perineum showing tissue necrosis with gas formation. C: Sagittal view of the thoracic CT scan showing gas formation tracking along the chest wall and superior mediastinum (arrows).

Figure 2. Status post incision and debridement of scrotum and perineum.

A 37-year-old man presented with worsening left testicular pain, swelling and redness within 3 days of being poked by a safety-pin during foreplay. Over 24 hours, his left scrotum doubled in size with significant erythema, edema, crepitus and induration. Imaging of scrotum and legs revealed extensive gas formation extending to the retroperitoneum and ascending along fascial planes. Subcutaneous emphysema of abdominal wall, chest wall with mediastinal gas was noted. Investigation showed a shite blood cell count of 22,000 cells/mcL with 12% bands and HIV testing was negative. Intravenous vancomycin and ertapenem were administered on presentation followed by emergent bilateral debridement of the scrotum. Wound/tissue cultures grew methicillin sensitive Staphylococcus aureus, group B Streptococcus and anaerobic Bacteroides. Antibiotics were de-escalated to ciprofloxacin and metronidazole and the patient showed adequate recovery at 30 days of follow up.

Improved survival of Fournier’s gangrene can only be achieved by prompt diagnosis, early debridement by an experienced surgical team and microbiology guided use of antibiotics.

Our case brings forward the act of piquerism, a paraphilia which led to rapidly progressive perineal tissue necrosis with bacterial synergism of non-clostridial micro-organisms causing extensive gas formation.

Padmastuti Akella, MD¹, Himmat Grewal MD¹, Imola Daniel MD²

¹Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA

²Division of Infectious Diseases, Saint Vincent Hospital, Worcester, MA

References 

1. Archer CB, Rosenberg WM, Scott GW, MacDonald DM. Progressive bacterial synergistic gangrene in patient with diabetes mellitus. J R Soc Med. 1984;77 Suppl 4:1-3. [PubMed]
2. Yasuda K, Hayashi M, Takeda N, Goshima E, Miura K. A survived case of diabetic nonclostridial gas gangrene and the review of the literatures on microbiological findings. Jpn J Med. 1986 May;25(2):171-4. [CrossRef] [PubMed]
3. Takazawa K, Otsuka H, Nakagawa Y, Inokuchi S. Clinical features of non-clostridial gas gangrene and risk factors for in-hospital mortality. Tokai J Exp Clin Med. 2015 Sep 20;40(3):124-9. [PubMed]
4. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-65. [CrossRef] [PubMed]

Cite as: Akella P, Grewal H, Daniel I. Medical image of the week: Fournier's gangrene with a twist. Southwest J Pulm Crit Care. 2018;17(1):28-9. doi: https://doi.org/10.13175/swjpcc083-18 PDF

Medical Image of the Week: Atypical Deep Sulcus Sign

Figure 1.  Chest X-ray showing hyper inflated lungs with no clear evidence of pneumothorax.

Figure 2. Atypical deep sulcus sign on the left side.

Figure 3. Complete resolution of left sided pneumothorax after chest tube placement.

The deep sulcus sign is a radiolucent lateral sulcus where the chest wall meets the diaphragm. The costophrenic angle is abnormally deepened when the pleural air collects laterally, producing the deep sulcus sign (1). Here, we present a 42-year-old man with a history of asthma who was admitted with status asthmaticus requiring intubation. On hospital day 3, the patient developed subcutaneous emphysema surrounding his entire neck and extending into left side of the chest wall. Chest X-ray after this episode showed an atypical deep sulcus sign (Figure 2) concerning for left sided pneumothorax that was also confirmed by bedside ultrasound. A surgical chest tube was placed immediately and a repeat chest X-ray (Figure 3) showed complete resolution of the pneumothorax and the deep sulcus sign. In critically ill patients where it is difficult to obtain an upright film, it is important to pay attention to the costophrenic angles when concern for pneumothorax arises. In a supine film, a deep sulcus sign may be the only indication of a pneumothorax because air collects anteriorly and basally within the nondependent portions of the pleural space, as opposed to the apex when the patient is upright (2).

Hasan Ali MD¹, Huthayfa Ateeli MBBS², Bhupinder Natt MD FACP², Sachin Chaudhary MD².

¹Department of Medicine and ²Division of Pulmonary, Critical Care, Sleep and Allergy

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Kim HK, Park CY, Cho HM. Deep sulcus sign. Trauma Image & Procedure. 2016;1(1):12-3. [CrossRef]
2. Liu SY, Tsai IT, Yang PJ. Pneumothorax and deep sulcus sign. QJM. 2016;109(9):621-2. [CrossRef] [PubMed]  

Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: atypical deep sulcus sign. Southwest J Pulm Crit Care. 2018;16(4):224-5. doi: https://doi.org/10.13175/swjpcc044-18 PDF 

April 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: A 19 year-old man with no previous medical history was vacationing when he was found down, intoxicated, surrounded by vomit. He went into cardiac arrest, and, after several minutes, cardiopulmonary resuscitation was initiated. He was intubated in the field, and epinephrine was administered.

Once at the hospital, frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate?

1. The frontal chest radiograph shows central venous catheter malposition
2. The frontal chest radiograph shows focal consideration
3. The frontal chest radiograph shows pleural fluid loculated within the major fissures
4. The frontal chest radiograph shows pneumomediastinum
5. The frontal chest radiograph shows pneumothorax

Cite as: Gotway MB. April 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4):137-46. doi: http://dx.doi.org/10.13175/swjpcc035-16 PDF

Medical Image of the Week: Boerhaave's Syndrome During Colonoscopy

Figure 1. Chest X ray showing bilateral subcutaneous emphysema extending from the supraclavicular area and above to the neck.

Figure 2. Video of representative coronal views of the thoracic CT scan showing subcutaneous emphysema in the supraclavicular area and neck.

Figure 3. Fluoroscopic esophagram revealing a focus of oral contrast actively extravasating (white arrow) approximately at 2.5 cm above the gastro-esophageal junction consistent with a small perforation.

A 76-year-old woman with no significant past medical history underwent outpatient screening colonoscopy. The procedure was difficult due to a tortuous colon and only multiple diverticula were visualized. She vomited once during the procedure. In the immediate postoperative period, she complained of neck swelling. Her vital signs were stable. On examination, right sided neck and facial swelling with palpable crepitations were noticed as well as coarse breath sounds heard on auscultation of both lung fields. Immediate chest X-ray (Figure 1) was obtained which showed bilateral subcutaneous emphysema extending from the supraclavicular area and above to the neck. Subsequent thoracic CT scan showed extensive subcutaneous air within the soft tissues of the neck bilaterally, extending into the mediastinum and along the anterior chest wall (Figure 2). An esophagram (Figure 3) revealed a focus of oral contrast actively extravasating approximately at 2.5 cm above the gastro-esophageal junction consistent with a small perforation. She underwent left thoracotomy with esophageal repair. Further hospital course was uncomplicated and she was discharged to a sub-acute rehabilitation facility. 

Boerhaave's syndrome is a spontaneous perforation of the esophagus due to sudden increase in intra-esophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting (1). The tear usually occurs at the left posterolateral wall of the lower third of the esophagus. Usually patients have severe retching and vomiting which is followed by excruciating retrosternal chest and upper abdominal pain after perforation. Other manifestations are odynophagia, tachypnea, dyspnea, fever, and shock. On physical examination subcutaneous emphysema (crepitation) is an important diagnostic feature. Chest radiograph usually reveals mediastinal or free peritoneal air as the initial manifestation, and hours to days later pleural effusion with or without pneumothorax, widened mediastinum, and subcutaneous emphysema are typically seen. The diagnosis of esophageal perforation can also be confirmed by water-soluble contrast esophagram using Gastrograffin, which reveals the location and extent of extravasation of contrast. Treatment depends upon the size and location of the perforation. Surgery is generally required for thoracic perforations while cervical perforations can often be managed conservatively with continuous nasogastric suction, intravenous broad-spectrum antibiotics, and parenteral nutrition.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD and Venu Ganipisetti MD

Department of Internal Medicine

Presence Saint Francis Hospital

Evanston, IL USA

Reference

1. Nirula R. Esophageal perforation. Surg Clin North Am. 2014;94(1):35-41. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: Boerhaave's syndrome during colonoscopy. Southwest J Pulm Crit Care. 2015;11(1):42-44. doi: http://dx.doi.org/10.13175/swjpcc058-15 PDF 

Medical Image of the Week: Pneumomediastinum

Figure 1. Chest X-ray PA view.

Figure 2. CT scan of chest.

A 38-year-old gentleman was flown to the emergency room after being involved in a motor vehicle accident. In the field, he had a Glasgow Coma Scale of about 7 and cricothyrotomy was performed to establish an airway. He sustained severe head and chest injuries, with extensive subcutaneous emphysema.  Chest X-ray (Figure 1) and CT scan (Figure 2) revealed pneumomediastinum with classical “continuous diaphragm sign” (red arrows), lucent streaks outlining the ascending aorta (blue arrows) and extensive subcutaneous emphysema (block arrows). Subdural and subarachnoid hemorrhage was detected on CT scan of head. His neurological status worsened over next 24 hours and he was confirmed brain dead.

Ramasubramanian Baalachandran MD, Naser Mahmoud MD, and Laura Meinke MD

Department of Medicine

University of Arizona

Tucson, Arizona

References

1. Bejvan SM, Godwin JD. Pneumomediastinum: old signs and new signs. AJR Am J Roentgenol. 1996;166:1041-8. [CrossRef] [PubMed]
2. Levin B. The continuous diaphragm sign. A newly-recognized sign of pneumomediastinum. Clin Radiol.1973;24(3):337-8. [CrossRef] [PubMed]

Reference as: Baalachandran R, Mahmoud N, Meinke L. Medical image of the week: pneumomediastinum. Southwest J Pulm Crit Care. 2014;9(3):189-90. doi: http://dx.doi.org/10.13175/swjpcc123-14 PDF

Medical Image of the Week: Bilateral Pneumothorax, Pneumomediastinum, and Massive Subcutaneous Emphysema

Figure 1.  Computed tomography of the thorax showing subcutaneous air dispersed in the adipose tissue, separating the fascia of the pectoralis major, and the delineation of its fibers (top arrow), pneumothorax compressing the lung (middle arrow), and pneumomediastinum compressing the trachea (bottom arrow).

An 80 year old man with chronic obstructive pulmonary disease (COPD) presented to the emergency department with respiratory distress and poor oxygen saturation. Physical exam revealed an obese male in respiratory distress with poor air entry bilaterally and scattered wheezing. His chest, neck, tongue, and lips were swollen. The patient was intubated for respiratory failure, felt to be due to angioedema. His oxygen saturation immediately improved, however the patient developed progressive swelling throughout his body including his eyelids, fingers and toes. Diffuse crepitus was felt on palpation. Chest radiography and computed tomography (CT) of the chest revealed large bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema (Figure 1). Bilateral chest tubes were inserted with re-expansion of both lungs. Over the next several days his respiratory parameters improved, with full re-expansion of the lungs and reabsorption of the pneumomediastinum and subcutaneous emphysema. The patient was extubated successfully and was discharged in good health.

Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema (SCE) are complications that may occur individually or rarely concomitantly, as in our case, during COPD exacerbations (the exact occurrence rate has not been described in the literature) (1-3). Bilateral spontaneous pneumthorax occurs in 1.9% of all spontaneous pneumothorax (4). The diagnosis is made with physical exam and appropriate imaging. Depending on the tension physiology, these conditions may lead to rapid respiratory failure and decreased cardiac output, especially when complicated by pulmonary barotrauma during mechanical ventilation (5,6).  In severe cases, SCE may involve respiratory compromise by compressing the trachea.

The early diagnosis with meticulous physical exam and relevant testing is essential, in order to immediately initiate appropriate management, and hence avoid the life-threatening complications associated with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema.

Zavier Ahmed MD, Manpreet Singh MD, Ricardo Lopez, MD

Icahn School of Medicine at Mount Sinai

Queens Hospital Center

82-68 164th Street

Queens, NY

References

1. Williams-Johnson J, Williams EW, Hart N, Maycock C, Bullock K, Ramphal P. Simultaneous spontaneous bilateral pneumothoraces in an asthmatic. West Indian Med J. 2008;57(5):508-10.[PubMed] 
2. Karakaya Z, Demir S, Sagay SS, Karakaya O, Ozdinc S. Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema: rare and fatal complications of asthma. Case Rep Emerg Med. 2012; 242579. [PubMed] 
3. Limthongkul S, Wongthim S, Udompanich V, Charoenlap P, Nuchprayoon C. Spontaneous pneumothorax in chronic obstructive pulmonary disease. J Med Assoc Thai. 1992;75(4):204-12. [PubMed] 
4. Athanassiadi K, Kalavrouziotis G, Loutsidis A, Hatzimichalis A, Bellenis I, Exarchos N. Treatment of spontaneous pneumothorax: ten-year experience. World J Surg, 1998;22: 803–6. [CrossRef] [PubMed] 
5. Hashim T, Chaudry AH, Ahmad K, Imhoff J, Khouzam R. Pneumomediastinum from a severe asthma attack. JAAPA. 2013;26(7):29-32. [CrossRef] [PubMed] 
6. Sakamoto A, Kogou Y, Matsumoto N, Nakazato M. Massive subcutaneous emphysema and pneumomediastinum following endotracheal intubation. Intern Med. 2013;52(15):1759. [CrossRef] [PubMed]

Reference as: Ahmed Z, Singh M, Lopez R. Medical image of the week: bilateral pneumothorax, pneumomediastinum, and massive subcutaneous emphysema. Southwest J Pulm Crit Care. 2014;8(3):181-2. doi: http://dx.doi.org/10.13175/swjpcc020-14 PDF

Medical Image of the Week: Pneumomediastinum

Figure 1.  Chest x-ray (CXR) shows subtle evidence of pneumomediastinum with air outlining left cardiac border and trachea (arrows).

 

Figure 2. Chest computerized tomography (CT) showing pneumomediastinum (Panel A) extending into lower neck (Panel B) without evidence of pneumothorax.

A 65 year old man presented with mild increase in shortness of breath. He had a past medical history of diabetes mellitus, hypertension, and severe malnutrition with percutaneous endoscopic gastrostomy (PEG) placement after a colectomy and end ileostomy for sigmoid volvulus. CXR (Figure 1) suggested a pneumomediastinum with subsequent chest CT (Figure 2) confirming moderate sized pneumomediastinum. He had a chronic cough from chronic obstructive pulmonary disease (COPD) as well as aspiration and chest CT also demonstrated emphysema with small blebs. He denied any significant chest pain. He was followed conservatively with imaging and discharged in stable condition.

Pneumomediastinum can be caused by trauma, esophageal rupture after vomiting (Boerhaave’s syndrome) and can be a spontaneous event if no obvious precipitating cause is identified (1). Valsalva maneuvers such as cough, sneeze, vomiting and childbirth, can all cause pneumomediastinum. Risk factors include asthma, COPD, interstitial lung disease and inhalational recreational drug use. Hamman's sign (a crunching sound in time with the heartbeat) can occasionally be heard.  More commonly, subcutaneous emphysema is felt on exam (crepitus). Complications can include single or bilateral pneumothorax, tension pneumothorax and pleural effusion. CXR often does not identify mediastinal air and CT imaging is highly sensitive and confirmatory. Conservative management is recommended with close clinical follow up for possible complications.

Rene Franco, Jr MD, Mohammad Dalabih MD, Janet Campion MD

University of Arizona Medical Center, Tucson AZ

Reference

1. Newcomb AE, Clarke CP. Spontaneous Pneumomediastinum. Chest. 2005;128:3298-3302. [CrossRef] [PubMed] 

Reference as: Franco R Jr, Dalabih M, Campion J. Medical image of the week: pneumomediastinum. Southwest J Pulm Crit Care. 2014:8(1):46-7. doi: http://dx.doi.org/10.13175/swjpcc160-13 PDF