Subcutaneous Emphysema in Adolescents: A Trap for The Unwary

Abstract A 16-year-old, Caucasian girl presented with sudden-onset pleuritic chest pain (CP), vomiting and shortness of breath. Nil past medical history; nil medications; nil trauma/ surgery. She was tachycardic, tachypnoeic and apyrexial with oxygen saturations >96% on air. There was significant right-sided facial and neck swelling. Chest palpation demonstrated crepitations suggesting subcutaneous emphysema (SE). Urinalysis was negative. Laboratory tests revealed leucocytosis and neutrophilia. Chest X-Ray: SE. CT Thorax: extensive gas within mediastinal cavity tracking along great vessels and within subcutaneous tissues with left, apical pneumothorax. Two air-filled tracts communicating between oesophagus and mediastinal cavity, ∼2cm from gastro-oesophageal junction, indicated oesophageal rupture. Conservative management included IV Fluids, antibiotics and feeding via total parenteral nutrition. After 1-week, oral water-soluble-contrast was administered. Subsequent imaging showed no evidence of extra-luminal extravasation and she was discharged. At 4-week follow-up, normal dietary intake was re-established with no complications. Discussion Boerhaave’s syndrome (BS) (described by Dutch physician Herman Boerhaave in 1724) is the phenomenon of spontaneous oesophageal perforation. The underlying mechanism is due to a sudden rise in intra-luminal pressure against a closed glottis resulting in barotrauma. BS in adolescents remains a rare entity with a paucity of reported cases. Mackler’s triad describes the classical presentation comprising vomiting, CP and SE. Non-specific presentation may delay diagnosis and a high clinical index of suspicion is required. CT thorax and water-soluble-contrast studies are diagnostic. Timing of presentation, complications and haemodynamic status dictate conservative or surgical management approach. BS carries a 20-40% mortality, and must be included in differential diagnoses of adolescents presenting with vomiting and CP.