Facial Oedema Is Not Always Angioedema: A Case of Spontaneous Pneumomediastinum with Subcutaneous Emphysema during COPD Exacerbation

Abstract

We report a case of acute facial oedema in an elderly hospitalized patient which was initially misdiagnosed as angioedema secondary to antibiotics in a patient with an allergic diathesis. We describe the differential aetiologies and then the true cause of the oedema, which was an uncommon complication of a very common condition in the elderly: a pneumomediastinum with subcutaneous emphysema probably due to rupture of an emphysematous lung bulla during chronic obstructive pulmonary disease (COPD) exacerbation. Lastly, we focus on the therapeutic procedures instituted for the treatment of the pneumomediastinum. LEARNING POINTS• It is difficult to collect medical history and drug allergy information from elderly hospitalized patients because of cognitive impairment or confusion.• When reviewing the differential diagnosis, it is very important to avoid fixation errors as they can seriously affect the patient's prognosis.• Unusual complications of extremely common chronic diseases among older people must also be considered during clinical reasoning. KEYWORDS Pneumomediastinum; COPD exacerbation; angioedema. CASE REPORT Two days after admission to a medical ward for chronic obstructive pulmonary disease (COPD) exacerbation, a 90-year-old woman affected by cognitive decline developed acute facial oedema, mainly localized in the periorbital and palpebral areas (Fig. 1). At admission she had not been able to reliably describe her medical history so she had been treated with levofloxacin, which was withdrawn 24 h later when her daughter reported a possible allergy to fluoroquinolones.