Pneumomediastinum and pneumorrhachis. Rare complications in pediatric age: case report and its management

ABSTRACT
Pneumomediastinum (PM) is an unusual and rare event in children. It is usually secondary to alveolar rupture in the pulmonary interstitium, followed by dissection of gas towards the hilum and mediastinum. Many events can lead to alveolar rupture, but the most common trigger factors in children are asthma and upper airway infections. Extremely rare is pediatric PM related to cardiac diseases, lung diseases such as pneumothorax, pulmonary embolism, thoracic traumatism, central airway perforation or digestive tract perforation and foreign body aspiration. The clinical diagnosis is based on the concomitant presence of chest pain, dyspnea, and subcutaneous emphysema that may affect face, neck and chest. In severe cases, pneumomediastinum may lead to a cardiac tamponade, induced by an increase in pressure in the mediastinal compartment to develop a severe obstacle venous flow back to the heart or in case of bacterial over-infection PM can lead to a mediastinitis. The diagnosis is confirmed by chest radiography and/or chest computerized tomography (CT). In most patients the air in the mediastinal compartment is slowly reabsorbed by neighbors’ tissues, favoring the spontaneous resolution of this condition. This process is also favored by the inhalation of high concentrations of low flow oxygen. In most cases conservative treatment such as bed rest and analgesics led to a rapid resolution of PM. The invasive surgical approach is necessary only in selected cases. It’s important to identify and treat all the possible underlying causes (if identified) and predisposing factors should be identified and controlled to prevent recurrence of PM. The combination of pneumomediastinum with pneumorrhachis (PR) rarely occurs in children. The present case report describes the presence of pneumomediastinum, subcutaneous emphysema, and pneumorrhachis in a child who had a history of persistent dry cough. A 9-year-old male child presented to our emergency service with respiratory distress, persistent dry cough, neck and chest pain. A chest X-ray and CT were performed and showed extensive pneumomediastinum with subcutaneous emphysema in neck area with no pneumothorax and concomitant air was in vertebral canal in the epidural space. Both clinical presentation and instrumental exams were consistent with those reported in the literature. The patient received noninvasive monitoring, analgesia, low flow oxygen, nebulized bronchodilators, intravenous steroids, and intravenous empiric antibiotics. This case highlights how PM and PR can be successfully managed conservatively and how an early diagnosis and management of the underlying cause is essential and important.

IMPACT STATEMENT
Asthma represents a significant health problem worldwide, and epidemiological studies in the last few decades have consistently shown a marked increase in childhood asthma prevalence. Asthma is infact recognized as the most common chronic disease in children with major public health consequences, including high morbidity and mortality in severe cases. Although asthma is recognized as the most common chronic disease in children, issues of underdiagnosis and undertreatment persist. Asthma treatment is based on a stepwise approach.
Furthermore while many official documents are present regarding asthma treatment, much less explored are all therapeutic options for related complications.
This manuscript highlights some rare and atypical complications of asthma exacerbations. Although these complications are typically benign and can resolve with supportive measures, severe cases can lead to acute airway compromise. This case also shows the importance of the knowledge of all therapeutic options but also the management of complication even if these are very rare and atypical and unusual.

Received: Oct 01, 2024
Accepted: Jan 14, 2025
Published: Jan 20, 2025