Case 1.
A 19-year-old gentleman with a history of occasional marijuana use presented with acute onset progressive central and sharp chest pain for several hours, followed by a brief syncopal episode. The pain was pleuritic and exacerbated on lying flat. He denied any trauma, fever, cough, retching, or vomiting. He did not have any previous history of hospitalizations. On presentation, the blood pressure was 117/79 mmHg with a pulse rate of 76 beats/min, temperature 37.7 °C (99.9 °F), and a respiratory rate of 22 breaths/min with an oxygen saturation of 96 % on ambient air. He did not have orthostasis. There was crepitus around the left lower neck, appreciated on palpation, and precordial auscultation was significant for a Hamman’s crunch best heard in the 4th left intercostal space suggestive of subcutaneous emphysema. Complete blood counts (CBC) revealed a white cell count (WBC) of 5.4x103, Hb 15 g/dl, platelets 241x103 per microlitre. EKG showed ST-segment elevations in the precordial leads (Figure 1a ). Serial troponins were negative. Chest X-ray revealed a continuous diaphragm sign suggestive of pneumomediastinum, which was confirmed by computed tomography (CT) of the chest showing evidence of spontaneous pneumomediastinum along with pneumopericardium (Figure 2a). The echocardiogram was unremarkable. An esophagram was not performed given the low suspicion for any esophageal rupture. The patient was successfully managed with mild analgesia, oxygen therapy, and clinical observation, with gradual resolution of EKG changes as the pneumopericardium resolved.