title: Trauma-induced "Macklin effect" with pneumothorax and large pneumomediastinum, disguised by allergy.
abstract: A 56-year-old man presented spontaneously to the Emergency Department complaining of facial and neck oedema after assumption of nonsteroidal anti-inflammatory drugs (NSAIDS). The triage nurse assigned the patient to Accident & Emergency (A&E) doctor as probable allergic reaction to NSAIDS. Chest X-ray (CXR), ordered after 24 hours, revealed a huge subcutaneous chest and neck emphysema without clearly visible pneumothorax. Subsequent chest CT scan showed a small left pneumothorax and a large amount of air in the mediastinum. The patient was conservatively treated since he was eupnoeic and hemodynamically stable. The pathophysiology of pneumomediastinum was first described by Macklin in 1939. The Macklin effect involves alveolar ruptures with air dissection along bronchovascular sheaths to the mediastinum. In this case the patient did not report in his history a recent blunt thoracic trauma and the initial suspicion of an allergic reaction has prevented physicians to immediately achieve the correct diagnosis.
authors.affiliation: Departments of Emergency and Surgery, Emergency Surgery and Trauma Surgery Unit, Trauma Center, Maggiore Hospital-Bologna Local Health District, Bologna, Italy. salo75@inwind.it
authors.forename: Salomone
authors.initials: S
authors.lastname: Di Saverio
authors.forename: Kenji
authors.initials: K
authors.lastname: Kawamukai
authors.forename: Andrea
authors.initials: A
authors.lastname: Biscardi
authors.forename: Silvia
authors.initials: S
authors.lastname: Villani
authors.forename: Luca
authors.initials: L
authors.lastname: Zucchini
authors.forename: Gregorio
authors.initials: G
authors.lastname: Tugnoli
mesh_terms: D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D006801:Humans; D008297:Male; D008478:Mediastinal Emphysema / Q000000981:diagnostic imaging / Q000209:etiology*; D008875:Middle Aged; D011030:Pneumothorax / Q000000981:diagnostic imaging / Q000209:etiology*; D012307:Risk Factors; D013898:Thoracic Injuries / Q000150:complications* / Q000503:physiopathology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000150:complications* / Q000503:physiopathology