Spontaneous cervical subcutaneous and mediastinal emphysema secondary to occult sigmoid diverticulitis

Abstract

We present a case of spontaneous mediastinal and subcutaneous cervical emphysema due to perforation of an occult sigmoid diverticulitis.Mediastinal emphysema should alert the physician to the possibility of retroperitoneal gastrointestinal perforation, even in patients without signs of distinct peritoneal irritation. Eur Respir J., 1995, 8, 2188-2190. Eur Respir J, 1995. 8, 2188-2190 DOI: 10.1183 Spontaneous supraclavicular emphysema is relatively common as a sequela of pulmonary interstitial emphysema and pneumomediastinum. It is often the result of alveolar wall rupture secondary to high intra-alveolar pressure caused by artificial ventilation, coughing, and straining [1]. However, it is quite rarely associated with intestinal perforation, particularly in cases with no history of instrumental manipulation of the hollow abdominal viscera [2]. Case reportA 67 year old woman was referred to our emergency service because of sudden onset of marked neck swelling for 2 h without concomitant dyspnoea. This was preceded by a slight lower back soreness for about 1 week. She had visited our orthopaedic clinic 3 days before, where degenerative disc disease with compression fracture of L4-5 was disclosed after radiographic imaging of the spine. The patient had previously been in good health, with the exception of diabetes mellitus, which had not been satisfactorily controlled.On physical examination, the patient appeared slightly ill-looking with a temperature of 36.4% blood pressure of 160/90 mmHg, pulse rate of 84 beats·min -1 , and respiratory rate of 16 breaths·min -1 . The patient's neck demonstrated swelling and crepitation, but no significant lymphadenopathy was found. Chest examination was normal. The abdomen was slightly distended and vaguely tender over the lower region, without signs of peritoneal irritation. Peristalsis remained active and bowel function was normal. However, knocking pain over both loins seemed equivocal. A chest roentgenogram demonstrated an unexpected pneumomediastinum, but no free air was apparent in the abdomen ( fig. 1).Complete blood count (CBC) showed a haemoglobin level of 141 g·L -1 , a white blood cell count (WBC) of 20.6×10 9 cells·L -1 and a platelet count of 218×10 9 ·L -1 . The faeces were positive (+++) for occult blood. Blood sugar level was 3.6 g·L -1 (normal range 0.7-1.1 g·L -1 ), and alkaline phosphatase was 147 U·L -1 (normal range 25-80 U·L -1 ). Fibreoptic bronchoscopic examination produced no evidence of pulmonary disruption. Gastroduodenoscopy was also performed, which revealed only multiple small gastric ulcers at the antrum, primarily along the side of greater curvature, and still with no sign of perforation. After 5 days of intravenous antibiotics and oral hypoglycaemic treatment, the WBC and glucose level returned to normal ranges.

Diverticular perforation: an unusual cause of subcutaneous emphysema

“…This case highlights the fact that, although uncommon, colonic perforation is a recognised cause of lower abdominal pain and supraclavicular subcutaneous emphysema due to intramesenteric, retroperitoneal and mediastinal gas tracking,1 in contrast to the usual finding in diverticular perforation—that is, intraperitoneal gas (pneumoperitoneum). It can be life-threatening and should be considered if the patient presents as above.…”

Proximal femoral osteomyelitis following a ruptured sigmoid diverticulitis—a case report and review of literature

“…Involvement of the hip or the thigh can occur either as a spread along the ilopsoas, Several unusual extraperitoneal manifestations have been reported in the literature as case reports. These have been inguinal abscess, perineal and buttock abscess [1], cervical subcutaneous emphysema [3], and scrotal abscess. In a review of 56 cases of thigh abscess, Rotstien et al found that more than 70% of these were originating from a colorectal pathology notably diverticulitis and colorectal cancer [4].…”

A rare presentation of a common disease

“…4 The descending rather than sigmoid colon is more likely to perforate this way because the former is fixed in the retroperitoneum. Furthermore since diverticula form where the blood vessels penetrate the bowel wall and because the sigmoid colon has a free mesentery, a diverticulum at this site will generally perforate into the peritoneal cavity.…”

“…In addition the high intra-abdominal and colonic pressure can lead to interstitial tracking of air upward to areas of low pressure resulting in pneumomediastinum 7. Subsequent rupture into the pleural cavity and subcutaneous tissue results in a pneumothorax8and surgical emphysema respectively 4…”