A 13-Year-Old Athlete With Chest Pain, Cough After Practice

Daniel Beardmore, DO; Sonika Loona, MD; Mia Mallon, MD


March 01, 2022


The patient described in this case presented with the unique finding of pneumomediastinum after prolonged physical activity, with the "exceptional radiographic finding" of pneumorrhachis—the presence of intraspinal air, as described and defined in a 2006 European Spine Journal review.[1]

Spontaneous pneumomediastinum is an uncommon finding in healthy pediatric patients, although the exact incidence is unknown.[2] The three main causes of spontaneous pneumomediastinum are alveolar rupture; perforation or rupture of the esophagus, trachea, or main bronchi; and dissection of air from the neck or abdomen. Most patients who develop pneumomediastinum do so owing to a significant prolonged or strong cough, which is a common symptom of many conditions, or through bronchospasm related to respiratory tract infection; both of these can lead to alveolar rupture. The usual course of recovery depends on the ability of the alveoli to heal, which is only possible if the cough can be suppressed or if the underlying condition improves.

Pneumomediastinum is discovered either by crepitus on examination or by identification of air outside the lungs on imaging. The imaging modality initially used determines whether further imaging is necessary for diagnosis; for example, in this case, the patient's pneumomediastinum was diagnosed on anteroposterior chest radiography, which prompted CT of the neck and chest. This revealed pneumopericardium, air in the pleural space, subcutaneous emphysema, and pneumorrhachis. Further workup depends on the circumstance of the individual case but may include complete blood count with differential and blood and/or sputum culture if respiratory tract infection is a concern.


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