Abstract Introduction Spontaneous pneumomediastinum typically results from elevated intra-alveolar pressure leading to alveolar rupture and air leakage into the mediastinum, triggered by vomiting, exertion, coughing, drug use, iatrogenic injury, or trauma. Patients with prior pulmonary diseases are particularly susceptible, as fragile alveoli are more prone to rupture under stress. Most cases of spontaneous pneumomediastinum are self-limited but do carry the potential for serious complications, such as pneumothorax, cardiovascular compression or compromise, pneumopericardium, and, rarely, pneumorrhachis. Given these risks, patients warrant close monitoring and thoughtful management to exclude complications. Description We report the case of a 19-year-old female with an eating disorder and chronic marijuana use who presented with 4 days of intractable vomiting, up to 10 episodes per hour at its peak. Initial evaluation at an outside hospital revealed pneumomediastinum on chest CT, prompting transfer for higher-level care and exclusion of esophageal perforation. X-ray esophagram showed no esophageal tear, and imaging and examination revealed no subcutaneous emphysema. She was managed with aggressive antiemetic therapy to control vomiting and prevent complications. Given her heavy cannabis use and recurrent emesis, the presentation was most consistent with cannabis hyperemesis syndrome, and she was counseled on cessation. Her symptoms improved, and she was discharged home. Discussion While pneumomediastinum is usually a benign, self-limiting condition treated conservatively, prompt recognition is critical to exclude life-threatening causes. Chest CT remains the diagnostic gold standard while fluoroscopic x-ray esophagography is preferred when perforation is suspected given high sensitivity and bronchoscopy may be warranted to evaluate tracheobronchial connections. When due to severe vomiting, Boerhaave Syndrome should be considered, as esophageal rupture carries high morbidity and mortality. Tracheobronchial injury, whether traumatic or iatrogenic, should also be excluded when a persistent air leak is suspected. Most spontaneous cases resolve with supportive care—including oxygen, analgesia, and antiemetics—though surgical repair may be required in complicated cases. Careful evaluation differentiates benign from critical etiologies, guiding management, and optimizing outcomes. Our patient had a rare case of vomiting-induced pneumomediastinum without esophageal rupture. This abstract is funded by: None
Jarovic et al. (Fri,) studied this question.