Yi Jiang, MD, Salil Chowdhury, BSc, Umair M. Nasir, DO, Hasan Ali, DO, Kandarp Suthar, DO, Kathleen Pergament, DO, MPH; Rutgers New Jersey Medical School, Newark, NJ
Introduction: Spontaneous pneumomediastinum (SPM) (Hamman’s syndrome), resulting from alveolar barotrauma, is a rare entity with a reported incidence ranging from 0.001% to 0.01% of all adult inpatients. It mainly affects young males with a tall, thin body habitus and the most common triggers are acute asthma exacerbation and lower respiratory tract infection. Despite typically being a self-limited condition with an excellent prognosis, SPM is frequently misdiagnosed as Boerhaave Syndrome (spontaneous perforation of the esophagus), which is associated with high mortality even with aggressive interventions. Here we report a curious case of SPM from cannabinoid hyperemesis syndrome as an uncommon trigger that confused clinicians during the initial presentation.
Methods: A 41-year-old African-American man (height 182.9cm, BMI 19.1kg/m2) with a history of tetrahydrocannabinol use disorder, cannabinoid hyperemesis syndrome, bipolar I disorder, and asthma was admitted involuntarily to the inpatient psychiatric unit for acute psychosis. During hospitalization, he developed worsening nausea and intractable vomiting and had more than 20 episodes of non-bilious, non-bloody vomitus over 12 hours. He denied fever, dysphagia, odynophagia, shortness of breath, cough, or chest pain. On the physical exam, the patient was alert and oriented, afebrile, not hypoxic, and not wheezing or stridorous. Abdominal exam revealed epigastric tenderness without rebound tenderness. Initial labs were unremarkable. CT chest, abdomen, and pelvis with contrast showed extensive pneumomediastinum with air tracked up into the soft tissues of the neck and supraclavicular region. The patient was transferred to a monitored medical bed, made nil per os, and started on broad-spectrum antibiotics. Both gastroenterology and cardiothoracic surgery were consulted given concern for esophageal perforation. The patient reported resolution of nausea and vomiting with anti-emetics and intravenous hydration. Formal review of the CT scan demonstrated no evidence of esophageal rupture. He remained hemodynamically stable and tolerated an advanced diet within 48 hours. Discussion: We report a rare case of SPM resulting from intractable vomiting in a patient with cannabinoid hyperemesis syndrome, which was initially confused with Boerhaave syndrome. Increased awareness among physicians of the differential diagnosis of pneumomediastinum and early recognition of the clinical characteristics of SPM may aid in better utilization of resources.
Figure 1. Extensive pneumomediastinum on CT scan with air tracked up into the soft tissues of the neck and supraclavicular region
Disclosures: Yi Jiang indicated no relevant financial relationships. Salil Chowdhury indicated no relevant financial relationships. Umair Nasir indicated no relevant financial relationships. Hasan Ali indicated no relevant financial relationships. Kandarp Suthar indicated no relevant financial relationships. Kathleen Pergament indicated no relevant financial relationships.