A 23–year–old male presented to the Emergency Room with symptoms of substernal chest pain radiating to his neck. The pain began spontaneously one day prior to arrival and progressed through the day. Subsequently he developed some “neck swelling”. Patient did not have any significant past medical history or family history of early cardiovascular disease. He denied having shortness of breath, vomiting, fevers, diaphoresis or nausea. His social history was remarkable for recent use of marijuana and inhalational cocaine. Physical exam showed a young male in mild distress with subcutaneous crepitations in his neck. Laboratory analysis was significant for positive urine drug screen for cocaine and cannabinoid. Chest X–ray (Image A) and CT scan of his neck and chest showed extensive subcutaneous emphysema in the neck soft tissues secondary to thoracic pneumomediastinum. Patient was placed on high flow oxygen and was admitted to the hospital for observation. Within 24 h, his symptoms resolved and physical exam revealed near complete resolution of his subcutaneous crepitations. Repeat Chest X–ray (Image B) showed significantly reduced pneumomediastinum. Consequently, patient was discharged with outpatient follow–up.
The differential diagnosis of acute chest pain in young adults usually includes acute coronary syndrome, pulmonary embolism, costochondritis, pericarditis, and gastroesophageal diseases. In addition, chest pain is a common presenting symptom of cocaine users in the Emergency Room, however majority of the cases are not acute myocardial infarctions, and other potential causes must be considered. Spontaneous pneumomediastinum is usually not considered but may present with acute chest pain in 93% of the cases. In inhalational cocaine users, the mechanism is believed to be due to an increase in pressure that occurs after smoking due to intentional production of a Valsalva maneuver to increase the absorption and maximize the effect of the drug. This maneuver results in alveolar overdistention. With alveolar overdistention and subsequent rupture, air dissects along the pulmonary vasculature toward the hilum and then extravasates into the mediastinum. Although, pneumonediastinum may sometimes progress to tension pneumothorax, in most cases it is benign and results in no physiologic abnormalities. A short observation period with outpatient follow–up is appropriate in majority of the patients.
The purpose of reporting this case is to increase general awareness of this overlooked cause of chest pain in young adults with history of cocaine use.
Image 1Arrows showing pneumomediastinum.
Image 2Arrows showing significant reduction in pneumomediastinum.