Spontaneous Pneumomediastinum from Running Sprints

Abstract

Spontaneous pneumomediastinum (SPM) is a fairly rare condition, caused by increased intrathoracic pressure, leading to free air in the mediastinal structures. Underlying lung conditions are associated with increased incidence of SPM, including asthma, interstitial lung disease, pneumonia, bullous lung, and radiation therapy for lung cancer. It is often preceded by Valsalva maneuvers, vomiting, coughing, asthma exacerbation, sneezing, childbirth, or intense physical activity. A case of SPM is presented in a 15-year-old male, who complained of throat pain and dyspnea while running sprints at football practice. Workup revealed SPM, and he was subsequently admitted and treated conservatively. His symptoms resolved in 2 days and he was discharged and suffered no further recurrences. In contrast to secondary pneumomediastinum, SPM is usually a benign condition although life-threatening conditions can rarely arise. Differentiating between these two conditions has important prognostic indications. There is a paucity of prospectively collected data regarding SPM, and considerable variation in recommendations concerning the extent of workup.

Pneumothorax in a young man with anorexia nervosa

“…The presumed pathophysiology to explain the development of the PSP appears to be a weakened lung architecture secondary to being a malnourished male with AN, 16 combined with increased intrathoracic pressure during vigorous exercise leading to rupture of perivascular alveoli. 17 It is indeed a surprise to us that this is the first reported case of an adolescent male with AN who vigorously exercises developing a PSP. This leads one to speculate as to whether there is a greater risk for misdiagnosis or underdiagnosis of PSP in this specific population.…”

“…Our patient had three of the above risk factors that made him at increased risk for development of PSP: malnourished secondary to AN, male gender and vigorous exercise. The presumed pathophysiology to explain the development of the PSP appears to be a weakened lung architecture secondary to being a malnourished male with AN, combined with increased intrathoracic pressure during vigorous exercise leading to rupture of perivascular alveoli …”

“…9 However, spontaneous pneumomediastinum (PSM) has been reported in an otherwise healthy 15-year old male (no identified underlying lung conditions and was not malnourished) who was running sprints. 17 The authors postulated that the sudden increase in intra-thoracic pressure during vigorous exercise was a risk factor for the development of PSM, and presumably PSP. This is a highly probable explanation for our patient who was running aggressively in gym class immediately preceding the onset of acute chest pain.…”

Spontaneous pneumomediastinum following pneumonia in a 23-year-old male patient

“…If there is a coexisting lung disease, the incidence of SPM increases. Asthma (8-39%), interstitial lung disease (18%), pneumonia, bullous lung disease, radiation therapy for the lung cancer are related with SPM [8]. Vomiting (24-36%), asthma attack (15-24%), coughing (7-35%), sneezing (13%), increased physical activity (30%), exertion during the birth (4-15%), shouting, deep breathing, diabetic ketoacidosis, Valsalva maneuver, sarcomas and drugs such as heroin or cocaine usually precipitate SPM.…”

“…Anorexia nervosa is also a predisposing state for SPM because of the diminished elasticity of the lung tissue. However, in 32-66% of the SPM cases, there is no precipitating cause [6][7][8][9]. Pneumomediastinum can be produced, in general, by three different mechanisms, as follows: i) gas-producing microorganisms present in an infection of the mediastinum or adjacent areas; ii) rupture (both traumatic or not) of the cutaneous or mucosal barriers, especially perforation of the esophagus or tracheobronchial tree, allowing air to enter the mediastinum; and iii) the existence of a decreasing pressure gradient between the alveoli and the lung interstitium that can result in alveolar rupture [10].…”