An 18-Year-Old Female with Sudden-Onset Chest Pain

Differential Diagnoses

• Pneumonia
• Pneumothorax
• Bronchiolitis
• Pneumomediastinum
• Status asthmaticus

Diagnosis
There is a thin curvilinear lucency outlining the mediastinal contour and heart border to the left of midline, indicative of pneumomediastinum.

Learnings/What to Look for

• The differential diagnosis of chest pain in an 18-year-old is age-specific, with frequent causes being musculoskeletal pain, pleurisy, anxiety, and, infrequently, acute coronary syndrome.
• Though infrequent, mediastinal air may be seen on an x-ray as a cause of chest pain.
• Extraluminal gas in the mediastinal space may originate from the lungs, trachea, bronchi, or peritoneal cavity.
• The most common etiology in pneumomediastinum is blunt trauma or vigorous exercise; however, it can be seen without clear etiology as idiopathic (as in this case).

Pearls for urgent care management and considerations for transfer:

• Often, no treatment is necessary, as the gas is slowly resorbed by the adjacent tissues.
• Conservative treatment (eg, administering oxygen) may facilitate quicker recovery.
• Patients with hemodynamic instability or fever or consideration for Boerhaave syndrome should be transported to the emergency department.

Acknowledgment: Image courtesy of Teleradiology Specialists.