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Table of Contents
LETTER TO THE EDITOR
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 91-92

Panic attack: An unusual cause of spontaneous pneumomediastinum


1 Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
2 Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA

Date of Web Publication3-Mar-2014

Correspondence Address:
Thomas J Papadimos
Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 west 10th Avenue, Room N417-C Doan Hall, Columbus, Ohio
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.128023

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How to cite this article:
Papadimos JS, Davis CS, Papadimos TJ. Panic attack: An unusual cause of spontaneous pneumomediastinum. Int J Crit Illn Inj Sci 2014;4:91-2

How to cite this URL:
Papadimos JS, Davis CS, Papadimos TJ. Panic attack: An unusual cause of spontaneous pneumomediastinum. Int J Crit Illn Inj Sci [serial online] 2014 [cited 2023 Mar 21];4:91-2. Available from: https://www.ijciis.org/text.asp?2014/4/1/91/128023

Sir,

pneumomediastinum (SPM) is common and usually benign and is frequently associated with blunt and penetrating trauma, infection, or esophageal rupture. [1] SPM was first reported by Laennec in the early 1800's and the first case series was presented in 1939. [1] The most common complaints are chest pain and dyspnea with the chest pain commonly described as pleuritic and retrosternal. [1]

Here we present a case of SPM associated with rapid vital capacity breaths over several hours secondary to a panic attack.

A 19-year-old female presented to the emergency department (ED) with a panic/anxiety attack of 3 h duration in which she complained that upon seating herself for an examination she became "nervous" and had "trouble breathing." She had no significant medical/surgical history. On examination she complained of facial numbness and paresthesias of her extremities. She further reported that since admission to the ED, she also had pain; "deep in my chest." She was alert, oriented, but looked distressed with heart rate of 105 beats/min, respiratory rate of 35-37/min, SpO 2 of 100% on 2 l nasal cannula, and blood pressure of 114/56 mmHg. Her lungs were clear and she had normal heart sounds. She was not diaphoretic, but her respirations were deep, near-vital capacity breaths, confirming her complaint of dyspnea.

She received 1 mg of intravenous midazolam and 500 ml of lactated Ringer's solution. Within 30 min, her pulse was 60 beats/min and respiratory rate 12-16 breaths/min. A chest X-ray was performed, which was normal [Figure 1]. No arterial blood gas was ordered. Her symptoms caused the ED physician to be concerned about a pulmonary embolus so a computed tomographic angiogram (CTA) was ordered which revealed a small pneumomediastinum along the left main stem bronchus [Figure 2]. She was hospitalization overnight for observation. Her chest pain resolved over several hours. The next day an esophagogram was performed to rule out esophageal tear/rupture; it was negative. An elective bronchoscopy was also performed looking for a bronchial perforation (48 h later as an outpatient) and it too was negative. The patient was discharged home without further incident.
Figure 1: Chest X-ray read as normal

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Figure 2: Computed tomography angiogram. Arrows identify sleeve of air near the esophagus and tracking along the left mainstem bronchus

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This is the first case in the literature that has been reported in association with a panic attack. Singla et al., have reported SPM in a Marine Corp Drill Instructor who developed SPM while shouting at recruits. [1] In this scenario, deep and forceful breaths expelled under pressure were the etiology. SPM has also been reported after stretching in which the symptoms were exacerbated by coughing. [2] It has also been associated with the poor dietary habits associated with anorexia nervosa. [3] It can be diagnosed by the use of X-ray, CT/CTA, or ultrasound in the appropriate clinical settings. [4] SPM usually does not require surgery and can be managed conservatively, if necessary, with bed rest, oxygen therapy, analgesia, and as in this case, also with sedation. [5] Our colleagues should be aware that tachypnea/hyperpnea, in the face of a panic attack, may be an etiologic cause of SPM.

 
   References Top

1.Singla M, Potocko J, Sanstead J, Pepper P. Ooh-rah! An unusual cause of spontaneous mediastinum. Mil Med 2012;177:1396-8.  Back to cited text no. 1
    
2.Breakey RW, Walker G, Oldfield W. Spontaneous pneumomediastinum presenting as rhinolalia and chest pain. Ann R Coll Surg Engl 2012;94:e243-5.  Back to cited text no. 2
    
3.Hochlehnert A, Lowe B, Bludau HB, Borst M, Zipfle S, Herzog W. Spontaneous pneumomediastinum in anorexia nervosa: A case report and review of the literature on pneumomediastinum and pneumothorax. Eur Eat Disord Rev 2010;18:107-15.  Back to cited text no. 3
    
4.Russo A, Giangregorio C. Pneumomediastinum: An extremely rare affection. A case of deferred diagnosis. Literature review and the role of thoracic US in urgency. Ann Ital Chir 2012;83:13-9.  Back to cited text no. 4
    
5.Alvarez ZC, Jadue TA, Rojas RF, Cerda CC, Ramirez VM, Cornejo SC. Spontaneous pneumomediastinum. Review of eight cases. Rev Med Chil 2009;137:1045-50.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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