Panic attack: An unusual cause of spontaneous pneumomediastinum.

Sir,

Spontaneous pneumomediastinum (SPM) is common and usually benign and is frequently associated with blunt and penetrating trauma, infection, or esophageal rupture.[1] SPM was first reported by Laennec in the early 1800's and the first case series was presented in 1939.[1] The most common complaints are chest pain and dyspnea with the chest pain commonly described as pleuritic and retrosternal.[1]

Here we present a case of SPM associated with rapid vital capacity breaths over several hours secondary to a panic attack.

A 19-year-old female presented to the emergency department (ED) with a panic/anxiety attack of 3 h duration in which she complained that upon seating herself for an examination she became “nervous” and had “trouble breathing.” She had no significant medical/surgical history. On examination she complained of facial numbness and paresthesias of her extremities. She further reported that since admission to the ED, she also had pain; “deep in my chest.” She was alert, oriented, but looked distressed with heart rate of 105 beats/min, respiratory rate of 35-37/min, SpO2 of 100% on 2 l nasal cannula, and blood pressure of 114/56 mmHg. Her lungs were clear and she had normal heart sounds. She was not diaphoretic, but her respirations were deep, near-vital capacity breaths, confirming her complaint of dyspnea.

She received 1 mg of intravenous midazolam and 500 ml of lactated Ringer's solution. Within 30 min, her pulse was 60 beats/min and respiratory rate 12-16 breaths/min. A chest X-ray was performed, which was normal [Figure 1]. No arterial blood gas was ordered. Her symptoms caused the ED physician to be concerned about a pulmonary embolus so a computed tomographic angiogram (CTA) was ordered which revealed a small pneumomediastinum along the left main stem bronchus [Figure 2]. She was hospitalization overnight for observation. Her chest pain resolved over several hours. The next day an esophagogram was performed to rule out esophageal tear/rupture; it was negative. An elective bronchoscopy was also performed looking for a bronchial perforation (48 h later as an outpatient) and it too was negative. The patient was discharged home without further incident.

Figure 1

Chest X-ray read as normal

Figure 2

Computed tomography angiogram. Arrows identify sleeve of air near the esophagus and tracking along the left mainstem bronchus

This is the first case in the literature that has been reported in association with a panic attack. Singla et al., have reported SPM in a Marine Corp Drill Instructor who developed SPM while shouting at recruits.[1] In this scenario, deep and forceful breaths expelled under pressure were the etiology. SPM has also been reported after stretching in which the symptoms were exacerbated by coughing.[2] It has also been associated with the poor dietary habits associated with anorexia nervosa.[3] It can be diagnosed by the use of X-ray, CT/CTA, or ultrasound in the appropriate clinical settings.[4] SPM usually does not require surgery and can be managed conservatively, if necessary, with bed rest, oxygen therapy, analgesia, and as in this case, also with sedation.[5] Our colleagues should be aware that tachypnea/hyperpnea, in the face of a panic attack, may be an etiologic cause of SPM.