Pneumomediastinum, pneumopericardium, and epidural pneumatosis in DKA
Introduction
Pneumomediastinum (PM) is the presence of air within the mediastinum. It is an uncommon condition that is reported to occur in 1 in 33,000 in the general population. The incidence of PM is highest in the population between the ages of 5 and 34 years in whom 1 in 25,000 individuals is afflicted (Abolink, Lossos, & Brewer, 1991). The clinical circumstances in which PM is encountered are varied but most commonly involve alveolar rupture that allows air to traverse along the bronchovascular bundle into the mediastinum. Most often, the disruption of the alveolus results from a condition or activity that produces high intrathoracic pressure.
PM is a rare complication of diabetic ketoacidosis (DKA) even though the pathophysiology of DKA commonly results in changes in pressure gradients in the lung alveoli secondary to vomiting and/or Kussmaul respirations. We report a 20-year-old male who presented in DKA and was found to have PM, pneumopericardium (PC), and epidural pneumatosis and review the world literature.
Section snippets
Case report
The patient, a 20-year-old male with diabetes mellitus since the age of 2 1/2 years of age, complained of a sore throat, fevers, and myalgias. He subsequently developed nausea and vomiting. After multiple episodes of vomiting and dry heaves, he experienced pleuritic left-sided chest pain. He denied rhinitis, cough, neck pain, aspiration of vomitus, and difficulty with defecation. He also denied recent trauma, vigorous athletic activity, dental procedures, and air travel. His past history was
Pathophysiology of PM
PM most commonly results from alveolar rupture that can occur in a variety of clinical settings. An increased positive pressure within the airways causes air to leak from the alveoli into the pulmonary interstitium, which then passes via the connective tissue of the broncho-arterial and veno-lymphatic bundles into the mediastinum (Schulman, Fataar, Van der Spuy, Morton, & Crosier, 1982) PM can also result from localized airway obstruction with distal air trapping. This “ball-valve” effect
Conclusion
We present a patient with the rare finding of PM associated with DKA. We also offer the unique observation of epidural pneumatosis associated with this metabolic derangement. During DKA changes in pressure gradients in the lung secondary to vomiting and/or Kussmaul respirations may lead to alveolar rupture and PM. Most patients with this complication are young males. PM in DKA may be relatively benign and the treatment is supportive. However, barotrauma manifesting itself as PC and/or
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