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.