Presentation
Hyperemesis and chest pain.
Patient Data
Extensive pneumomediastinum. Surgical emphysema is seen in the supraclavicular soft tissues bilaterally and extending into the axillae and the neck. No pneumothorax or subdiaphragmatic gas.
There is extensive pneumomediastinum with surgical emphysema extending into the neck and the upper chest wall. Furthermore, the gas extends into the paravertebral soft tissue as well as the spinal epidural space from the cervicothoracic junction to the level of T12. There is gas in the inferior pulmonary ligaments and intersublobar septa which are continuous with the mediastinum.
In the distal esophagus just above the diaphragm, the lumen appears to be outlined by contrast, and there appears to be equivocal mural thickening posterolateral, possibly due to motion. There is no contrast extravasation.
The imaged upper abdominal viscera are unremarkable. There is no pericardial or pleural effusion. Patchy ground glass opacities are present in the right upper and lower lobes.
Conclusion:
Extensive pneumomediastinum, surgical emphysema in the neck and the chest wall, and epidural emphysema in the thoracic spine. The site of the perforation has not been definitely demonstrated.
Case Discussion
Clinically, hyperemesis was thought to be attributable to substantial cannabis consumption (cannabis hyperemesis syndrome). Unfortunately, the patient refused to stay in the hospital and self-discharged the following day. They have been lost to follow-up.
Pneumorrhachis is a generic term that denotes the presence of gas within the spinal canal, both intra- and extra-thecal. In this instance, it resulted from direct extension from the mediastinum due to a rupture of either the distal esophagus or airways.
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