Volume 6, Case 12
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 6 year old male who presents to the emergency department at 10:30 pm with chest pain and difficulty breathing. He has had the pain since the afternoon which is located in his anterior chest but its quality is difficult for him to characterize. His pain is worse when coughing and taking a deep breath. He has been coughing a lot and this has been worsening over the past 2 days. He felt warm last night, but his temperature was not measured. He has not had a fever since then.
His past medical history is negative for asthma, pneumonia and heart disease. He has been largely healthy to date. His immunizations are up to date. His family history is unremarkable.
Exam: VS T37.5, P125, R25, BP 107/65, oxygen saturation 97% in room air. He is alert and comfortable in no acute distress. He is not toxic and not irritable. HEENT unremarkable except for minimal nasal congestion. Neck supple without adenopathy. His chest wall is non-tender over the ribs and sternum. He does have some increased chest pain with deep inspiration. Heart regular, good tones, no rubs, murmurs or gallops. Lung auscultation reveals moderately decreased aeration. No wheezing is heard but he is not moving air well. He has a bronchospastic sounding cough. Abdomen soft, non-tender, bowel sounds are active. His back is non-tender. His extremities show good pulses and perfusion. No peripheral edema is evident.
A chest radiograph and an EKG are ordered.
View chest radiographs.
View PA.
View lateral.
His 12-lead EKG is normal. His chest radiographs demonstrate the cause of his pain.
The differential of chest pain in children includes cardiogenic causes such as percarditis, myocarditis, endocarditis, etc., due to various etiologies. Coronary artery disease in children is uncommon.
Non-cardiogenic causes include musculoskeletal etiologies, pneumonia, pulmonary air leaks, other pulmonary conditions, abdominal etiologies, aortic conditions, etc. Most of these conditions can be recognized or at least suspected on routine chest radiographs.
Our patient's chest radiographs demonstrate a pneumomediastinum.
There is evidence of subcutaneous emphysema in the neck on the PA view. Note the air densities in the patient's neck which is more prominent on the patient's right (arrows), there is also some air dissection on the patient's left (arrow). The remainder of the PA view is unremarkable. The usual vertical air densities seen closer to the lungs in a pneumomediastinum on the PA view are not evident here. The lateral view shows a prominent air collection anterior to the heart just above the diaphragm (arrow). There is a prominent air density outline of the trachea on the lateral view (arrow points to a double outline of the tracheal air column) which is again suggestive of pneumomediastinum. The common finding of seeing thymic demarcation and linear air densities in the anterior mediastinum is not evident here.
Refer to Case 7 of Volume 1 (Hamman's Sign) for a more complete discussion of pneumomediastinum.
He is given an albuterol aerosol which results in improvement in his aeration. Mild wheezing is noted. He feels much better and his chest pain is minimal. He is discharged on an albuterol inhaler with a spacer with instructions to return if his discomfort worsens. He is to see is primary care physician in the morning.