Pneumomediastinum in a smoking free-base cocaine abuser during sexual intercourse

Abstract

Case: 21-year-old man.Chief complaint: Retrosternal chest pain.Clinical history: There were no pathologies in family history. He did not take any medications. He was smoking 10 cigarettes daily. He was a habitual cocaine user. The patient had a blood pressure of 120/80 mmHg, a resting heart rate of 73 beats/minute, a respiratory rate of 16 breaths/minute, an oxygen saturation of 98%, and no temperature. The main symptom was an initial sharp retrosternal chest pain starting 5 hours before in the course of free-base cocaine smoking. Dyspnea and retrosternal pain were increasing with breath and chest movements. The pain was intensifying 2 hours earlier during sexual intercourse with a female partner. Then, the retrosternal pain was constant as regards intensity and localization. Subcutaneous emphysema of the neck was palpable on physical examination. Inspiratory effort and elicited rib pain was evident on chest examination. Cardiopulmonary auscultation and electrocardiography were normal.Laboratory findings: Blood tests were normal; urine drug analysis was positive for cocaine. Image findingsChest X-ray (CXR) revealed clear lung fields, pneumomediastinum (PM) and emphysema in the soft tissues between the muscles of the neck ( Figure 1a). Pulmonary computed tomography (CT) without contrast showed pneumomediastinum (PM), i.e. air dissecting tissue planes extending in the soft tissues of the neck, including the muscles, the nerves, the right rear second back rib and the ipsilateral front first and second anterior rib, all the mediastinal recesses (also anterior) and the bilateral peribronchial and paraesophageal spaces until the diaphragmatic hiatus. CT also showed a solution of continuity of the right postero-lateral portion of the trachea with adjacent minimum hypo-dense material (Figures 2a, 3a, 4a). In emergency department, the application of human fibrin glue by means of bronchoscopy was used to seal the tracheal lesion. CXR showed complete resolution of the PM and subcutaneous emphysema after 12 days (Figure 1b). Chest CT without contrast also revealed complete resolution at 15 days ( Figures 2b, 3b, 4b). DiscussionPM was consequent to tracheal rupture due to Valsalva maneuver during both smoking free-base cocaine use and sexual activity. PM consequent to barotrauma is a possible finding in patients with cocaineinduced pulmonary disease [1]. Barotrauma is a complication related to cocaine inhalation [2] or crack smoking [3]. It is the consequence of an increased airway and intrathoracic pressure due to intentional production of Valsalva maneuvers and episodes of coughing after smoking, in an attempt to absorb the maximal amount of drug. The rupture of alveoli into the interstitium and the mediastinum frequently produces PM after over-distension against a closed glottis. Our case report is particular as regards the etiology of PM, i.e. tracheobronchial tree laceration consequent to Valsalva maneuvers and tracheobronchial wall fragility due to the direct toxicity of the cocaine on the lung tissue after repeated i...