Hamman's Syndrome: A Rare Consequence for a Common Vice

Abstract

INTRODUCTION:Roughly 42 million Americans have reported trying cocaine via myriad methods in their lifetime. Since the early 2000s, spontaneous pneumomediastinum as a result of intranasal cocaine use has been demonstrated though it remains a relatively rare occurrence. Though complications such as coronary vasospasm and thrombosis may prove a greater threat to life, it should remain a part of the clinician's differential when treating a patient with a history of cocaine abuse and chest pain. CASE PRESENTATION:A healthy 20-year-old male presented with chest pain, cough, and neck pain for 3 days. He was drinking with a friend and "snorted" cocaine a few times on the same night. A few hours into the evening, he experienced a sudden, sharp retrosternal chest pain, without radiation, and exacerbated by deep breathing. He denied trauma and denied vomiting, dry heaving, gagging, or other symptoms to cause concern for GI perforation as cause, despite drinking heavily that night.On evaluation, his oxygen saturation measured 98% on room air with normal pulse, blood pressure and temperature. Physical examination revealed extensive neck and chest wall subcutaneous emphysema. Electrocardiogram demonstrated normal sinus rhythm without arrhythmias or segmental changes. CT of the chest demonstrated large amounts of air in the superior mediastinum. Based on his history, severity of presentation, and laboratory investigations, there was no concern for mediastinitis or esophageal rupture. He did not require oxygen supplementation and his pain was well controlled, so he was discharged to his home. DISCUSSION: In 1939, Louis Virgil Hamman (1877-1946 described the co-occurrence of subcutaneous emphysema with spontaneous pneumomediastinum, thus coining the term Hamman's Syndrome for this particular malady. Subcutaneous emphysema occurs primarily within the head and neck due to anatomical proximity to the airway and pneumomediastinum as a result of cocaine insufflation is thought to be due to barotrauma, with rapid changes in intrathoracic and intra-alveolar pressures as the individual snorts and performs Valsalva maneuver. Though typically self-limited, complications of spontaneous pneumomediastinum to be aware of include airway compression, pneumopericardium, and mediastinitis.CONCLUSIONS: In a case of Hamman's Syndrome without a history of illicit drug use or trauma, it is prudent to investigate other secondary causes of spontaneous pneumomediastinum, such as esophageal or tracheobronchial rupture, that can prove fatal. Particularly in young males who abuse cocaine, the astute clinician must search for underlying causes of chest pain with recent drug use: coronary artery spasm or thrombosis, arrhythmia, pneumothorax, or pneumomediastinum.