Spontaneous pneumomediastinum (SPM) is a relatively uncommon occurrence. Although unlikely, asthma exacerbations can produce enough barotrauma to produce this complication. In cases of SPM, the gas has the opportunity to track between fascial planes, making its way to subcutaneous tissues, usually of the neck and chest, resulting in subcutaneous emphysema (SE). In anomalous situations, this gas can track its way into the retropharyngeal space. This presentation is usually self-limiting, requiring supportive therapy. Severe cases can lead to airway compromise warranting invasive supportive airway maneuvers. Retropharyngeal emphysema, SE, and pneumomediastinum have rarely been described together in the literature. This case provides awareness of these three complications of asthma, while highlighting the need for deliberate chest imaging, including radiograph and non-contrast CT, in patients with severe asthma exacerbations.

Anticholinergic toxicity is a relatively uncommon occurrence. When it does occur, it is usually attributed to an overdose of anticholinergic agents, especially in the elderly population. In younger patients, anticholingeric toxicity is usually due to an intentional overdose in a suicide attempt, accidental exposure to jimson weed or deadly nightshade plant, or the combination of anticholinergic drugs with recreational drugs (psilocybin mushroom). Over-the-counter cold medicines are well known to contain a variety of anticholinergic substances, the most well-known being diphenhydramine. Uncommonly, these readily available substances can produce anticholinergic toxicity in elderly patients, even when appropriate dosages are consumed. Younger patients are less likely to develop this clinical picture, due to higher renal clearance and lower drug volume of distribution. Nonetheless, clinical suspicion should remain high in the younger population. Patients can present with fever, tachycardia, diplopia, urinary retention, dry mucous membranes, and altered mental status. This case provides awareness to the unlikely complication of over-the-counter cold medicines in a young 19-year-old patient, while highlighting the need for diligent history taking and deliberate use of physostigmine in patients with altered mental status.