Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

A CASE OF PNEUMOMEDiASTiNUM iN A TRiATHLETE JACK GOLDER OMS-ii & LiNDSAY TJiATTAS-SALESKi DO, MBA EDWARD ViA COLLEGE OF OSTEOPATHiC MEDiCiNE - CAROLiNAS CAMPUS PRiSMA HEALTH UPSTATE 1 1, 2 1 2

Imaging

Abstract

Case

A 23-year-old male with no prior medical history presented to the emergency department with sharp pleuritic chest pain and dyspnea , which began eight hours earlier after a 3.5-hour biking session during Ironman training. He was physically active with a history of marathon running and collegiate rowing. The patient denied the use of alcohol, tobacco, or drug products, and had no recent respiratory infections. On examination, he appeared comfortable with vital signs showing a blood pressure of 150/83 mmHg, heart rate of 138 beats per minute, oxygen saturation of 100%, and temperature of 37.5 ° C. He was tall and thin with a BMI of 20.2 . The cardiovascular exam revealed tachycardia but no murmurs, and lung auscultation was clear. No chest wall tenderness was noted. Lab tests showed normal cardiac enzymes , ruling out acute coronary syndrome. A D-Dimer was not conducted. A complete blood count and metabolic panel were unremarkable, except for mild hypokalemia and elevated creatine phosphokinase attributed to recent exercise. An ECG showed sinus tachycardia and diffuse ST segment depression . While the chest X-ray was normal, a chest CT with contrast revealed a moderate volume pneumomediastinum extending into the neck’s visceral fat planes. Cardiothoracic surgery was consulted, and a fluoroscopic barium swallow ruled out esophageal rupture. The patient was treated with IV fluids and ketorolac, admitted for observation, and discharged 24 hours later with instructions for symptomatic care, follow-up with a cardiologist, and cessation of triathlon training for six weeks.

Introduction 1 The mediastinum, located in the central thoracic cavity, houses vital structures such as the heart, great vessels, and trachea. 1 Pneumomediastinum, or mediastinal emphysema, occurs when air enters this space, often due to alveolar rupture from pressure 1 . Although rare, with an incidence of 22 cases per million emergency visits, spontaneous pneumomediastinum (SPM) is most common in young men aged 19-25. 2 Traditional risk factors include smoking, drug use, and lung disease such as asthma, however, in rare incidences, SPM can be brought on by intense physical exertion. 3 Prompt diagnosis is essential due to its variable presentation and potential complications. References 1. Mahabadi et al., Anatomy, Thorax, Lung Pleura And Mediastinum. StatPearls. Treasure Island: March 24, 2024. 2. Tapias L.F., & Wright C.D. 2023. Nonneoplastic disorders of the mediastinum. Fishman's Pulmonary Diseases and Disorders, 6e. McGraw-Hill Education. Barroso D, Rocha D, Abelha Pereira F, et al. Spontaneous 3. Pneumomediastinum: A Rare Cause of Chest Pain. Cureus. 2023;15(10):e47015. Published 2023 Oct 14. 4. Dirol, H., & Keskin, H. (2022). Risk factors for mediastinitis and mortality in pneumomediastinum. Journal of cardiovascular and thoracic research, 14(1), 42 – 46. https://doi.org/10.34172/jcvtr.2022.09 1 2,3 4 Spontaneous pneumomediastinum is a rare condition, often linked to smoking, drug use, asthma, or barotrauma, but can also occur after intense exercise, particularly in tall, thin males. In this case, a 23-year-old male with no prior medical history presented with chest pain and dyspnea following triathlon training. Despite a normal chest X-ray, a CT scan revealed pneumomediastinum. The patient was admitted for observation and treated conservatively. Physicians should consider pneumomediastinum in young patients with chest pain, as it can mimic serious cardiopulmonary conditions.

Electrocardiogram ~ Sinus tachycardia with diffuse ST depression

AP Chest X-Ray ~ No Acute Findings

Sagittal & Axial CT PE ~ Impression of Moderate Volume Pneumomediastinum

5 Discussion SPM is a rare and often misdiagnosed condition due to its varied clinical presentation, mimicking serious issues such as acute coronary syndrome or pulmonary embolism. While risk factors such as smoking and lung disease increase the likelihood of development, this case illustrates that SPM can occur without these triggers, furthering the need for a detailed history and physical exam. Though traditionally noninfectious and benign, misdiagnosis of SPM can result in further progression, leading to serious complications such as mediastinitis and tension pneumothorax. 4 Though limited in its generalizability, this case highlights the need to consider this condition in the differential diagnosis for young athletes presenting with chest pain following intense training.

2025 Research Recognition Day

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