PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA AS A RARE COMPLICATION OF RHINOVIRUS AND EPSTEIN BARR VIRUS CO-INFECTION
Roman Perez HI, Kalapurakal GT, Deleveaux S, Rahim F, and Fuentes XF. PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA AS A RARE COMPLICATION OF RHINOVIRUS AND EPSTEIN BARR VIRUS CO-INFECTION. J Gen Intern Med 2023; 38:S513-S514.
J Gen Intern Med
CASE: A 22-year-old female with no known past medical history presented to the emergency department with progressively worsening shortness of breath, chest pain, and vomiting. She endorsed one week of flu- like symptoms and on the day before admission, experienced episodes of non-bloody emesis with acutely worsening dyspnea and chest pain. Physical examination was significant for pharyngeal and bilateral tonsillar swelling, bilateral sternocleidomastoid muscle crepitus, tachycardia and tachypnea. Investigation demonstrated mildly elevated white blood cell count to 12.7 K/mcL and arterial blood gas showing a mild respiratory alkalosis with pH of 7.47, positive Epstein Barr Virus (EBV) capsid IgM titers, and viral respiratory panel positive for Rhinovirus. Computed Tomography Angiogram of the Chest showed no evidence for pulmonary embolism (PE), but extensive pneumomediastinum along the esophagus, throughout the mediastinum, and contiguous with soft tissue emphysema in the bilateral lower neck. An esophagram study with contrast was normal with no evidence of esophagitis, esophageal laceration, nor esophageal leak suggestive of esophageal rupture. The patient was diagnosed with Spontaneous Pneumomediastinum (SPM). She showed clinical improvement with intravenous Ampicillin/Sulbactam and Fluconazole, along with supportive measures.
IMPACT/DISCUSSION: Spontaneous Pneumomediastinum most commonly presents in those with existing lung disease, trauma, or recent surgical procedure after a triggering event such as emesis or cough. SPM occurs from alveolar rupture due to high intra-alveolar pressures, low peri-vascular pressures, or both. Patients with SPM complain of chest pain, commonly pleuritic, cough, and shortness of breath. Infrequently, viral respiratory illnesses can cause SPM with Influenza virus as the most common agent reported. Viruses less commonly responsible include EBV and Rhinovirus. EBV is a ubiquitous virus that often presents as a subclinical infection in most adults, while Rhinovirus is the most common virologic agent behind the common cold. The proposed mechanism for viral agents causing SPM include damage to the alveolar cell wall or intense coughing, or both. While EBV and Rhinovirus can cause mild cough, there have only been a few case reports that describe Rhinovirus induced SPM, all of which have involved the pediatric population. In fact, to our knowledge, there has only been one case of SPM reported in the adult population secondary to Rhinovirus and EBV co-infection.
CONCLUSION: Patients who present with chief complaints of sudden onset dyspnea and chest pain should be evaluated for life threatinening conditions Acute Coronary Syndrome, PE, and Pneumonia. Once those conditions are ruled out, clinicians should explore the possibliity of SPM regardless of age or past medical history.