Medical Mystery -- The Answer

doi:10.1056/NEJM200003093421014

Volume 342:740		March 9, 2000		Number 10

Medical Mystery — The Answer

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To the Editor: The medical mystery in the January 20 issue¹involved a 79-year-old woman who presented to the emergencydepartment with a several-hour history of facial swelling (Figure 1A).She had chronic obstructive pulmonary disease. The swellingof her head and neck had developed and progressed in a few hours,despite antihistamine and glucocorticoid treatment. She hadfallen on her left side two days before admission. Physicalexamination revealed massive symmetric subcutaneous emphysemathat involved the whole upper part of the body and the arms,extending to the fingernails. A chest film (Figure 1B) and acomputed tomographic (CT) scan (Figure 1C) confirmed the presenceof extensive subcutaneous and mediastinal emphysema, with arib fracture (arrows). A traumatic anterior pneumothorax waspresent on the left side, which could be seen only on the CTscan. The loss of elasticity with increased closing volume inthe patient's lungs probably prevented a total pneumothorax.The emphysema resolved in a few days after the placement ofa chest tube. The photograph shown in Panel D of Figure 1 wastaken seven days after the photograph shown in Panel A.

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Figure 1. A 79-Year-Old Woman with Facial Swelling.
The patient went to the emergency room because of facial swelling of several hours' duration (Panel A). A chest film (Panel B) and a CT scan (Panel C) showed extensive subcutaneous and mediastinal emphysema, with a rib fracture (Panels B and C, arrows). After the placement of a chest tube, the emphysema resolved (Panel D).

Michiel G.H. Betjes, M.D., Ph.D.
Academic Medical Center
1105AZ Amsterdam, the Netherlands

Editor's note: We received 969 responses to this medical mystery.About 31 percent of the respondents suggested subcutaneous emphysemaas the diagnosis. The most common diagnosis was an acute allergicreaction, which was suggested by about 34 percent of the respondents.In this category, we included diagnoses involving a varietyof terms, such as angioedema, allergy, and anaphylactic reaction.About 14 percent of the respondents — and 42 percent ofthose who suggested an allergic reaction — said that hairdye was the culprit, because the patient's hair looked grayerin the second photograph of the Image (Fig. 1D here) than inthe first (Fig. 1A). Another 19 percent thought that the patienthad the superior vena cava syndrome. A few respondents mentioneda possible problem with the nasal cannula as the cause of eithersubcutaneous emphysema or an allergic reaction to latex. Otherresponses included hypothyroidism and Pancoast's tumor.

References

Betjes MGH. A medical mystery. N Engl J Med 2000;342:176-176. [Free Full Text]