An unusual cause of chest painBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3004 (Published 12 August 2009) Cite this as: BMJ 2009;339:b3004
- Madhuchanda Bhattacharyya, specialist registrar,
- Minaxi Dattani, specialist registrar
- 1Department of Radiology, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ
- Correspondence to: M Bhattacharyya
A 66 year old woman presented to the accident and emergency department with severe chest pain radiating to the back following several episodes of vomiting after a meal.
On examination, she was unwell with tachycardia and tachypnoea. Her blood pressure was 150/80 mm Hg in the left arm and 138/80 mm Hg in the right arm. Her past medical history included asthma, hypertension, and a previous transient ischaemic attack.
On admission, she had a mildly raised white blood cell count (14.3×109/l) with neutrophilia (8.58×109/l) and normal haemoglobin (143 g/l). Serum lactate was raised (3.6 mmol/l), but urea and electrolytes were normal. Chest radiography was performed and showed a right sided pleural effusion. Aortic dissection was suspected, and she underwent computed tomography of the chest, abdomen, and pelvis using an aortic protocol. The scan showed a pneumomediastinum with an associated pneumothorax and a right sided pleural effusion. Further radiological investigation was performed (fig 1⇓).
1 What is meant by the term pneumomediastinum?
2 What radiological investigation has been performed and what does it show?
3 What is the diagnosis?
4 How would you manage this patient?
1 Pneumomediastinum is the presence of gas in the mediastinal tissues outside the oesophagus and tracheobronchial tree.
2 This study is a water soluble contrast swallow. It is used in suspected oesophageal rupture to demonstrate a leak from the oesophagus into the mediastinum (fig 2⇓).