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A6635 - Blown by Blow: An Usual Etiology of Pneumomediastinum
Author Block: O. Ishikawa1, H. Jen2; 1Internal Medicine, Northwell Health Lenox Hill Hospital, New York, NY, United States, 2Internal Medicine, Stony Brook University, Stony Brook, NY, United States.
Cocaine is a widely abused drug worldwide with a myriad of toxicities. While many of its cardiovascular and neurologic effects are well-known and quickly identifiable, literature on pulmonary complications remain limited. We describe a case of a rare pulmonary complication of intranasal cocaine use leading to pneumomediastinum.
Our patient is a 35 year-old male with a past medical history notable for asthma and polysubstance abuse, who was brought in after an accidental heroin and cocaine overdose. Patient had used heroin two nights prior to admission in addition to intranasal cocaine. On admission, he was lethargic and complained of right thigh and chest pain where he had fallen and had bruised. He also had mild shortness of breath and a dry cough but denied any other complaints. Physical exam was significant for mild tachycardia and small ecchymoses along the right lateral thigh and anterior chest. Labs were significant for acute renal failure with a serum creatinine of 5.0 and a creatinine kinase level of >10,000 consistent with rhabdomyolysis induced kidney injury. Urine toxicology was positive for cocaine and opiates. Chest radiograph showed subcutaneous emphysema with evidence of pneumomediastinum. An x-ray esophagram showed no evidence of esophageal perforation. CT scan with contrast was also performed which confirmed the pneumomediastinum, however also showed no evidence of esophageal perforation. Patient was treated conservatively for cocaine-induced pneumomediastinum with intravenous Ampicillin / Sulbactam and monitored with serial chest radiographs. He was eventually discharged home after full recovery.
Pneumomediastinum is the presence of air in the mediastinum. Both intranasal and inhalation use of cocaine has been identified as a cause for pneumomediastinum. The proposed mechanism is a sequence of events that starts with inhalation of cocaine inducing bronchospasm and increased alveolar pressure, with eventual rupture leading to interstitial emphysema and pneumomediastinum. Alternatively, it also may be caused by gastrointestinal microperforations secondary to pre-existing mucosal weakness and/ or esophagitis, combined with valsalva action during intoxication. Most cases of pneumomediastinum secondary to cocaine use are benign, and a short observation period with appropriate follow-up is appropriate in the majority of patients. While chest pain is a common presenting symptom of cocaine intoxication, pneumomediastinum should be considered on the differential and screened for with physical exam and imaging.