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Indian Pediatr 2011;48:
976-977 |
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Spontaneous Pneumomediastinum in H1N1
Infection |
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PK Patra, Uma S Nayak and TS Sushma
From the Department of Pediatrics, Government Medical
College and SSG Hospital, Vadodara, India.
Correspondence to: Dr PK Patra, Assistant Professor,
Department of Pediatrics, Govt Medical College &
SSG Hospital, Vadodora 390 001, India.
Email:
[email protected]
Received: November 3, 2009;
Initial review: January 22, 2010;
Accepted: August 23, 2010.
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Spontaneous pneumomediastinum is an uncommon pediatric emergency which
usually occurs secondary to bronchial asthma in children. We report a
case of spontaneous pneumomediastinum in a 7 year child following
Swine Flu (H1N1) infection.
Key words: Complication, Management,
Pneumomediastinum, Swine flu.
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Spontaneous pneumomediastinum in children is
triggered by asthma, vomiting, situations reproducing the Valsalva
maneuver (e.g. shouting, coughing, inhalation of drugs, and intense sport
activities [1]. We report an unusual spontaneous pneumomediastinum caused
by Swine Flu (H1N1) infection. Very few similar cases are reported till
date [2].
Case Report
A 7-year-old female child presented with severe cough,
high grade fever and breathlessness for 3 days prior to admission. At
admission, she had maculopapular rash all over the body, sore throat and
tachypnea. Respiratory system examination revealed fine crepitation
bilaterally. All other systemic examination was within normal limit.
Hemoglobin was 10.2 g/dL and total leukocyte count was 4200 cells/cumm
with lymphocytic (70%) predominance. Blood culture and endotracheal
aspirate culture revealed no growth. Chest X–ray revealed bilateral
streaky opacities. A throat and nasal swab was sent to rule out Novel
H1N1. She was put on broad spectrum antibiotics, intravenous fluid and
oseltamivir. After 48 hours of admission, she developed severe stabbing
chest pain. This was accompanied with subcutaneous emphysema along with
deteriorating oxygen saturation. Blood gas analysis revealed (pH 7.51,
PaO 2 50mmHg, PCO2 28, Spo2 90%, HCO3
26, BE 2.4, AaDo2 70 mmHg). Chest
X-ray revealed underlying pneumomediastinum. The child was put on
pressure control mode of mechanical ventilation. Trachostomy was done, as
the subcutaneous emphysema was increasing. Following six hours of
tracheostomy, there was complete disappearance of mediastinal air with
total resolution of subcutaneous emphysema at 24 hourss. The child was
weaned off from mechanical ventilation. However, the child developed Acute
respiratory distress syndrome (ARDS) on day 7 of admission and died.
Discussion
The index case had no other apparent risk factor apart
from vigorous cough in addition to severe H1N1 infection, which is known
to cause diffuse alveolar damage and interstitial pneumonitis leading to
the development of spontaneous pneumomediastinum. Accompanying subcutaneous
emphysema compresses the trachea and can worsen the respiratory condition
and we experienced a similar complication in our case. Although mechanical
ventilation may cause air leaks, including pneumomediastinum, continuing
it and even escalating respiratory support may be necessary depending on
the severity of the underlying respiratory distress and the degree of
compromise caused by the air leak. Principle objectives include the use of
the lowest pressures or tidal volumes necessary to achieve satisfactory
carbon dioxide removal and oxygenation [3]. There are case reports of use
of high frequency oscillatory ventilation in pneumomediastinum,
especially when it is associated with ARDS. However, further research is
needed to support these findings [4].
Surgical intervention has rarely been described in
pneumomediastinum. Its use is reserved for pneumomediastinum leading to
marked cardio-respiratory compromise. Cervical mediastinotomy with or
without tracheostomy is life saving in these cases [5]. We found
tracheostomy to be useful in our condition.
To conclude, H1N1 infection can give rise to an unusual
air leak syndrome like spontaneous pneumomediastinum and subcutaneous
emphysema in children. If required, tracheostomy is helpful.
Contributors: All authors contributed to diagnosis,
literature search and drafting the manuscript.
Funding: None.
Competing interests: None stated.
References
1. Chalumeau M, Clainche Le L, Sayeg N, Sannier N,
Michel LJ, Marianowski R et al. Spontaneous pneumomedia-stinum in
children.Pediatr Pulmnol. 2001;31:67-75.
2. Hasegawa M, Hashimoto K, Moruzumi M, Ubukata K,
Takahashi T, Inamo Y. Spontaneous pneumomediastinum complicating pneumonia
in children infected with 2009 pandemic influenza A (H1N1) virus. Clin
Microbiol Infect. 2010;16:195-9.
3. Patric LC. Pneumomediastinum: treatment and
medication. Available from http:// emedicine medscape.com/article//1003409-treatment.
Accessed on March 30, 2010.
4. Tonelli RA, Ruiz-Rodriguezs O, Jeminez JE.
Successful use of high-frequency oscillator ventilation for acute
respiratory distress syndrome with pneumomedia-stinum.Respiratory Medicine
CME. 2009;2:173-5.
5. Caceres M, Ali ZS, Braud R, Weiman D, Garrett E.
Spontaneous pneumomediastinum: A comparative study and review of the
literature. Ann Thorac Surg. 2008;86:962-6.
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