Spontaneous pneumomediastinum – a rare cause of chest pain and dyspnoe in children

Introduction. Spontaneous pneumomediastinum is a very rare condition in children. Nevertheless it should be considered in the differential diagnosis in patients who present with chest pain and dyspnoe.Aim. The aim of our study was to describe clinical presentation, management and outcomes of the paediatric patients with spontaneous pneumomediastinumMaterial and Methods. This was a retrospective analysis of the charts of all the patients who were admitted to the Department of Pneumonology, Paediatric Allergy and Clinical Immunology in a ten year period from 01.01.2011 till 31.12.2020 in whom spontaneous pneumomediastinum was diagnosed.Results. There were 11 children (7 females) with spontaneous pneumomediastinum. The median age of the children was 11 years (range 3 to 17.5 years). Most of the children presented to the hospital with chest pain, three children complained of the neck swelling and four children developed dyspnoe. Three children with the primary spontaneous pneumomediastinum had a history of physical exercise prior to the onset of symptoms. The secondary spontaneous pneumomediastinum occurred in two children with asthma and 4 children with pneumonia. Genetic material of human Bocavirus was identified in 3 cases. In 81.8% of children pneumomediastinum was accompanied by subcutaneous emphysema and in one case, in a child with severe pneumonia and respiratory insufficiency caused by Bocavirus with pneumorrhachis. In 10 children computed tomography was performed, bronchoscopy in 4 and esophagoscopy in two children. There was no evidence of esophageal rupture or bronchial tree rupture in any of our patients. Three children with pneumonia and pneumomediastinum developed respiratory insufficiency, two of these were treated with mechanical ventilation and one with High Flow Nasal Cannula oxygen therapy. All the children received oxygen. In one child surgical procedure was performed and the drain was inserted into mediastinal space in order to decompress it. Outcome was favourable in all children. Mean time to recovery was 10.6 ± 1.2 days. There was no recurrence of symptoms in any of our patients.Conclusions. Spontaneous pneumomediastinum in most cases is a benign condition, sporadically however it may progress rapidly, leading to respiratory insufficiency and warrant invasive management.

Improvement of surgical methods for the treatment of spontaneous rupture of the esophagus ­complicated by purulent mediastinitis

Aim. To improve surgical treatment outcomes of patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis. Methods. Over the past 30 years, we have experience in the surgical treatment of 31 patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis. Depending on the tactics and techniques of surgical treatment, we identified two groups of patients. The first group (n=8) consisted of patients operated with conventional techniques: thoracotomy, transpleural mediastinotomy according to Dobromyslov, suturing of the esophagus with drainage of the mediastinum and pleural cavities, blind mediastinal drainage. The second group (n=23) consisted of patients treated with programmed re-thoracotomy. Re-thoracotomy was performed along with the postoperative thoracotomy wounds. The delimited foci of purulent mediastinitis were opened and sanitized (necrotic tissues were excised and removed). Preventive hemostatic methods were used in the area of pressure ulcers from drainage tubes. Replacing and changing the position of the drainage tubes in the mediastinum was a strictly compulsory technique. Pus and necrotic soft tissue that appeared in the thoracotomy wound were subsequently eliminated by a device consisting of two titanium brackets connected by a lock embodied in the form of an oval ring during the wound suturing at the stage of programmed re-thoracotomy. The groups were comparable in age and comorbidities. The average diagnosis of spontaneous esophageal rupture took 3.5 days; the maximum time is 10 days. The statistical significance of differences in immune status indicators was assessed by using the Student's t-test and Pearson's 2 test. Results. A systematic approach using the tactical and technical surgical techniques developed by us (such as suturing esophageal wall defects regardless of the rupture time, multifunctional nasoesophagogastric tube installation; the imposition of a purse string suture to prevent reflux from the stomach into the esophagus; programmed re-thoracotomy using the method of temporary fixation of the ribs) allowed to reduce the number of complications, such as haemorrhage from the mediastinal vessels, by 3 times, sepsis 1.5 times, mortality almost 2 times. Conclusion. The introduction of patented techniques allowed to reduce the number of life-threatening complications and mortality in patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis.

Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis

Background Boerhaave syndrome is an uncommon condition that represents about 15% of all esophageal perforation. A subset of these patients has eosinophilic esophagitis, a chronic inflammatory disease of the esophagus, that carries a risk of perforation of about 2%. Esophageal perforations can rarely result in the development of an esophago-pleural fistula. Treatment of esophago-pleural fistula represent a challenge due to lack of high quality evidence and scarce reported experience. Endoluminal vacuum-assisted therapy could have a role in the management by using the same principle applied in external wounds which provide wound drainage and tissue granulation. Case presentation We report a unique case of a 24-year-old man with eosinophilic esophagitis complicated with an esophageal rupture who developed an esophago-pleural fistula and was successfully managed with a non-surgical approach using endoluminal vacuum-assisted therapy. To our knowledge this could be the first experience reported in a patient with eosinophilic esophagitis. Conclusion Endoluminal vacuum-assisted therapy might be an effective and novel strategy in patients with eosinophilic esophagitis and esophago-pleural fistula as a consequence of Boerhaave syndrome. Appropriately designed studies are required.

Esophageal Rupture Presenting with ST Segment Elevation and Junctional Rhythm Mimicking Acute Myocardial Infarction

Esophageal rupture is a rare but potentially fatal cause of chest pain. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory distress. Over the next 48 hours, the patient developed dynamic ST segment changes on surface electrocardiogram mimicking an inferolateral ST segment elevation MI accompanied by a junctional rhythm. Curiously, his cardiac enzymes remained negative during this time, but his clinical status continued to deteriorate. A subsequent CT scan demonstrated a lower esophageal rupture, and the patient underwent successful endoscopic stenting. While rare, prompt recognition of esophageal rupture is imperative to improving morbidity and mortality. While esophageal rupture has been noted to cause ST segment elevation before, this appears to be the first case associated with a junctional rhythm.

Candida Empyema Thoracis at Two Academic Medical Centers: New Insights Into Treatment and Outcomes

Background Candida empyema thoracis (pleural empyema) is an uncommon manifestation of invasive candidiasis, for which optimal treatment is unknown. Methods This is a retrospective study of patients with Candida empyema at 2 academic medical centers from September 2006 through December 2015. Results We identified 81 patients with Candida empyema (median age, 62 years; 68% men). Sixty-five percent of patients underwent surgery or an invasive intervention of the thorax or abdomen within the preceding 90 days. Candida empyema originated from intrathoracic (51%) or intra-abdominal sources (20%), spontaneous esophageal rupture (12%), pleural space manipulation (9%), and pneumonia (6%). Eighty-four percent and 41% of patients were intensive care unit residents and in septic shock, respectively, within 3 days of diagnosis. Causative species were Candida albicans (65%), Candida glabrata (26%), Candida parapsilosis (11%), Candida tropicalis (4%), Candida krusei (2%), and Candida dubliniensis (1%). Bacteria were recovered from empyemas in 51% of patients. Concurrent candidemia was diagnosed in only 2% of patients. Management included pleural drainage and antifungal treatment in 98% and 85% of patients, respectively. Mortality at 100 days was 27%, and it was highest for cases stemming from esophageal rupture (67%). Spontaneous esophageal rupture and echinocandin rather than fluconazole treatment were independent risk factors for death at 100 days (P = .003 and .04, respectively); receipt of antifungal therapy was an independent predictor of survival (P = .046). Conclusions Candida empyema mortality rates were lower than reported previously. Optimal management included pleural drainage and fluconazole treatment. Superiority of fluconazole over echinocandins against Candida empyema needs to be confirmed in future studies.

Spontaneous esophageal rupture following perforated peptic ulcer: a report of two cases

Background Spontaneous esophageal rupture, also called Boerhaave’s syndrome, is relatively uncommon but may result in high morbidity and mortality. Synchronous presentation of spontaneous esophageal rupture and perforated peptic ulcer was rare and may contribute to the difficulty of achieving a correct diagnosis. Case presentation We reported two patients with spontaneous esophageal rupture following perforated peptic ulcer. Both patients were successfully treated with thoracoscopic primary repair of esophageal rupture. The first patient underwent peptic ulcer repair via laparotomy. The second patient underwent laparoscopic duodenorrhaphy. Both patients resumed oral intake smoothly and were discharged uneventfully. Conclusion Minimally invasive approaches are safe and feasible for both esophageal rupture and perforated peptic ulcer in patients diagnosed within 24 h and without shock.