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A 70-year-old woman who had been taking oral steroids with tapering after an acute exacerbation of idiopathic pulmonary fibrosis (IPF) was diagnosed with stage IIIB squamous cell lung cancer by transbronchial lung biopsy from left hilum 6 months before admission. At the time, she had anorexia due to

Primary pneumomediastinum is the presence of air in the interstitium of the mediastinum. The exact aetiology is unclear; nevertheless, it has been reported more frequently in patients with asthma and in individuals who use recreational drugs. It is commonly preceded by a sharp rise in intrathoracic pressure as in a Valsalva-like manoeuvre. We describe a rare case of severe pneumomediastinum with a small pneumothorax related to cannabis smoking and aggravated by vigorous sexual intercourse. The patient was successfully treated conservatively due to clinical and radiological stability and the absence of secondary cause.

Objectives: Pneumomediastinum (PM) secondary to oromaxillofacial trauma (OMF) is a rare but well-described complication/pathologic finding. The aim of this study was twofold: first, to report our experience in treatment of maxillofacial trauma patients with PM, and second, to review the literature regarding the clinical features, severity, course, and management of the aforementioned complication. Material and methods: We retrospectively reviewed the medical records and charts of patients who suffered from maxillofacial trauma and treated in our hospital between September 1, 2013 and September 31, 2017. The inclusion criteria were patients with radiologically confirmed PM. In addition, the electronic databases PubMed, Scopus, and Science Direct were queried for articles reporting PM cases secondary to OMF injuries and published in English, French, and German language. Results: Three cases of PM out of 3,514 cases of craniomaxillofacial trauma were found; there were 3 male patients who presented in our emergency department with the chief complaint of cervicofacial swelling. Literature search isolated 58 selected articles and 63 cases were assessed in total; posttraumatic repeated blowing of nose was proved as most frequent triggering factor among them. Furthermore, the outcomes of review showed that thoracic pain, respiratory distress, and swallowing difficulties were not frequently reported in patients with ME due to facial trauma. Conclusions: Both our experience and the results of systematic literature review indicated that patients with PM due to OMF injuries present mild clinical course. If properly managed, this specific pathologic condition may have no further complications or relative comorbidities. The exact etiology and mechanism of PM in the context of maxillofacial injuries always needs to be identified. Radiographic, laboratory, and endoscopic examinations should be applied to rule out the more serious and frequently diagnosed aerodigestive, thoracic, and abdominal causes of PM.

Rapid evolution of pulmonary complications associated with severe COVID-19 pneumonia often pose a management challenge to clinicians especially in the critical care setting. Serial chest imaging enable clinicians to better monitor disease progression and identify potential complications early which may decrease the mortality and morbidity associated with COVID-19. We report a case of severe COVID-19 pneumonia in a 69-year-old man that presented to University Malaya Medical Centre in March 2020 with multiple pulmonary complications including lung cavitation, bronchopleural fistula, pneumothorax, pneumomediastinum, subcutaneous emphysema and acute pulmonary embolism which we highlight through serial chest radiographs (CXR) and computed tomography (CT). The patient unfortunately succumbed to his disease one month after admission. COVID-19 patients may develop pulmonary complications due to a combination of direct viral lung damage, hypoxemia and high stress ventilation. Awareness of COVID-19 complications can prompt early diagnosis and timely management to reduce morbidity and mortality. Keywords: COVID-19 case report, lung cavitation, bronchopleural fistula, pneumothorax, pneumomediastinum.

There are several injuries potentially related to high-G exposure, including neck and back pain, spinal fractures, and pneumomediastinum. We present a young military pilot diagnosed with isolated fractures of the right 9th and 10th ribs via X-ray after high-G exposure (maximum G level: 9G). This patient presented with progressive and localized pain in the right anterior chest and flank region. After conservative treatment with rest and pain management, he recovered from the rib fractures and completed all profile challenges in the advanced high-G training program. A review of the annual health examination of the pilot did not show any rib lesions or other related illnesses. He was qualified for flying class II and considered fit for flight training. His medication history was unremarkable, and he did not have a family history of malignancy, osteoporosis, or osteopenia. He also denied having previously experienced trauma of the rib cage or participated in any strenuous military training program or exercise before centrifuge training. The potential explanations for the multiple rib fractures are repetitive stress from the anti-G straining maneuver and anti-G suit compression of the abdominal bladder. To our knowledge, consecutive rib fractures related to high-G exposure have never been documented. This report may increase the awareness of flight surgeons and training units regarding the risk of chest wall injuries during high-G exposure and encourage them to use multiple diagnostic tools to determine the correct diagnosis.

Primary spontaneous pneumomediastinum (SPM) is a rare clinical entity in children. It may arise in isolation or is associated with other complications.[1–4][1] Benign and self-limited, it is usually managed conservatively, with spontaneous resolution in most cases.[1–4][1] We present the case

A 15-year-old man presented with an acute history of facial swelling following a bout of forceful eructation after eating. Subcutaneous emphysema was noted on examination of his left face and neck. He was initially managed with intravenous antibiotics for suspected facial infection. A chest radiograph performed on day 3 of admission identified subcutaneous emphysema of the upper thorax and neck. CT with oral contrast confirmed extensive subcutaneous emphysema of neck, thorax and upper abdomen, with associated pneumomediastinum. The site of air leak was not identified. He subsequently underwent upper gastrointestinal endoscopy and this was normal. Despite the delay in diagnosis, he remained haemodynamically stable, and repeated radiography showed improvement reflecting the benign course of this condition as described in existing literature. There are no previous published reports of spontaneous pneumomediastinum following eructation; therefore, high clinical suspicion should be maintained in this presentation.

Introduction Air leak consisting of pneumothorax, pneumomediastinum, and subcutaneous emphysema has been described as one of the complications of coronavirus disease-2019 (COVID-19) infection affecting disease course and outcome. We aimed to conduct a systematic review of published literature to highlight the risk factors, types, and outcomes in COVID-19. Method A systematic search of PubMed, Embase, Scopus, and Google Scholar was performed from November 1, 2019, to February 28, 2021. Seventy-one studies fulfilled the inclusion criteria and 136 adult patients were included in the final analysis. Results Majority of patients were male (75.2%) with the mean age of 58 years. Hypertension was the most common comorbidity followed by diabetes mellitus. Moreover, 12.5% of patients had a history of smoking while 11.7% had preexisting lung disease. Isolated pneumothorax (48.5%) was the most common and 17.65% had developed spontaneous pneumothorax. Mean onset time was 11.6 days and 67% of patients required an intercostal drainage tube for management. Mortality was 40%, and elderly, female gender, obese and hypertensive were at higher risk. Conclusion COVID-19-related air leaks are associated with higher mortality and longer hospital stay and can occur even without positive pressure ventilation. History of smoking and preexisting lung disease has not been shown to increase the incidence of air leak. A well-designed study is required for a better understanding of COVID-19-related air leak. How to cite this article Singh A, Singh Y, Pangasa N, Khanna P, Trikha A. Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review. Indian J Crit Care Med 2021;25(12):1434–1445.

Background/aim: As the number of case reports related to the new type of coronavirus (COVID-19) increases, knowledge of and experience with the virus and its complications also increase. Pleural complications are one relevant issue. We aimed in this study to analyze pleural complications, such as pneumothorax, pneumomediastinum, and empyema, in patients hospitalized with the diagnosis of COVID-19 pneumonia. Materials and methods: The files of patients who have pleural complications of COVID-19 pneumonia and were consulted about thoracic surgery between March 2020 and December 2020 were retrospectively reviewed. The data of the patients were analyzed according to age, sex, length of stay, treatment method for pleural complications, mortality, severity of COVID-19 pneumonia, tube thoracostomy duration, and presence of a mechanical ventilator. Results: A total of 31 patients fulfilling the inclusion criteria were included in the study. There were 11 female (35.5%) and 20 male (65.5%) patients. The most common complication was pneumothorax in 20 patients (65%). The median duration of hospitalization was 22 days and the mortality rate was 71%. Mortality was significantly higher in patients on mechanical ventilation (p = 0.04). Conclusion: The mortality rate is very high in patients with pleural complications of COVID-19 pneumonia. Pneumothorax is a fatal complication in critically ill patients with COVID-19 pneumonia.

Spontaneous pneumomediastinum is an infrequent complication of COVID-19. The mechanism is still unknown and thought to be related to patient self-inflicted lung injury. Our patient is a 49-year-old male who presented with shortness of breath and cough. A COVID-19 Polymerase Chain Reaction was positive. He required a high-flow nasal cannula, but he did not demand mechanical ventilation. Computed tomography angiography scan of the chest revealed pneumomediastinum. He was managed conservatively, and a complete recovery was achieved. This case highlights the emerging association of COVID-19, patient self-inflicted lung injury, and pneumomediastinum. Furthermore, spontaneous pneumomediastinum should be suspected even in patients who were not mechanically ventilated.

Purpose: To determine whether Macklin effect (a linear collection of air contiguous to the bronchovascular sheath) on baseline CT imaging is an accurate predictor for subsequent pneumomediastinum (PMD)/pneumothorax (PNX) development in invasively ventilated patients with COVID-19-related acute respiratory distress syndrome (ARDS). Materials and methods: This is an observational, case-control study. From a prospectively acquired database, all consecutive invasively ventilated COVID-19 ARDS patients who underwent at least one baseline chest CT scan during the study time period (February 25th, 2020–December 31st, 2020) were identified; those who had tracheal lesion or already had PMD/PNX at the time of the first available chest imaging were excluded. Results: 37/173 (21.4%) patients enrolled had PMD/PNX; specifically, 20 (11.5%) had PMD, 10 (5.8%) PNX, 7 (4%) both. 33/37 patients with subsequent PMD/PNX had Macklin effect on baseline CT (89.2%, true positives) 8.5 days [range, 1–18] before the first actual radiological evidence of PMD/PNX. Conversely, 6/136 patients without PMD/PNX (4.4%, false positives) demonstrated Macklin effect (p < 0.001). Macklin effect yielded a sensitivity of 89.2% (95% confidence interval [CI]: 74.6–96.9), a specificity of 95.6% (95% CI: 90.6–98.4), a positive predictive value (PV) of 84.5% (95% CI: 71.3–92.3), a negative PV of 97.1% (95% CI: 74.6–96.9) and an accuracy of 94.2% (95% CI: 89.6–97.2) in predicting PMD/PNX (AUC:0.924). Conclusions: Macklin effect accurately predicts, 8.5 days in advance, PMD/PNX development in COVID-19 ARDS patients.

Background Paraquat (1,1-dimethyl-4,4-bipyridinium dichloride) is a toxic herbicide. Accidental ingestion of paraquat in animals and humans causes respiratory failure and death. Aim To describe the radiographic features of confirmed paraquat intoxication in a group of dogs and determines whether any identified features can facilitate this diagnosis. Methods Eleven dogs diagnosed with paraquat intoxication were selected from two institutions between November 2014 and August 2019 comprising five males (all intact) and six females (one intact and five spayed). The mean age was 3.9 ± 2.9 (SD) years and their mean weight was 11.6 ± 5.0 kg. The tentative diagnosis was confirmed through analysis of their urine samples using a colorimetric assay (paraquat concentation 0.39 μg/ml ranging from 0.19-0.65 μg/ml), and their clinical signs were reviewed. Thoracic radiographs were evaluated for the presence of pneumomediastinum, lung patterns (interstitial or alveolar) and their locations (caudodorsal, cranioventral, diffuse, or symmetrical), subcutaneous emphysema, pneumoretroperitoneum, and pneumothorax. Results The most common clinical signs were dyspnea (11/11, 100%) and anorexia (9/11, 82%). Pneumomediastinum (10/11, 91%) and symmetrically increased lung opacity (7/11, 65%) were the most common radiographic features. Pneumothorax (3/11, 27%), pleural effusion (3/11, 27%), subcutaneous emphysema (2/11, 18%), and pneumoretroperitoneum (1/5, 20%) were the less common findings. None of the dogs survived. Conclusion Pneumomediastinum and diffuse or symmetrical interstitial or alveolar lung patterns are the most common radiographic features in dogs with paraquat intoxication. Clinical relevance In countries where this herbicide is not banned, paraquat intoxication should be considered if dogs with no history of trauma present with pneumomediastinum.

Tracheal tear after endotracheal intubation is extremely rare. The role of silicone Y-stent in the management of tracheal injury has been documented in the previous studies. However, none of the studies have mentioned the deployment of silicone Y-stent via rigid bronchoscope with the patient solely supported by extracorporeal membrane oxygenation (ECMO) without general anaesthesia delivered via the side port of the rigid bronchoscope. We report a patient who had a tracheal tear due to endotracheal tube migration following a routine video-assisted thoracoscopic surgery sympathectomy, which was successfully managed with silicone Y-stent insertion. Procedure was done while she was undergoing ECMO; hence, no ventilator connection to the side port of the rigid scope was required. This was our first experience in performing Y-stent insertion fully under ECMO, and the patient had a successful recovery.

OBJECTIVES In this study, we aimed to establish risk factors for primary spontaneous pneumomediastinum associated with Coronavirus disease 2019 (COVID-19) and reveal those which are significant. METHODS The study included 62 patients with primary spontaneous pneumomediastinum who presented to our hospital between 11 March 2020, the date of the first-reported COVID-19 case in our country, and 3 January 2021. Of these, 14 patients (22.6%) had COVID-19 and 48 patients (77.4%) did not have COVID-19. RESULTS Of the 62 patients included in the study, 41 (66.1%) were male and 21 (33.9%) were female. The mean age was 28.90 ± 16.86 (range, 16–84) years. The most common symptom at admission was chest pain (54.8%). The mean age of the patients with COVID-19 was 39.35 ± 23.04 years and that of the patients without COVID-19 was 25.85 ± 13.45 years (P < 0.001). In receiver-operating characteristic curve analysis, the area under the curve for age was 0.785 (95% confidence interval: 0.648–0.922) and the optimal cut-off value was 24 years for COVID-19-positive patients. The highest sensitivity and specificity values were 0.857 and 0.729. Twelve (85.79%) of the COVID-19-positive primary spontaneous pneumomediastinum patients were aged 24 years or older (P < 0.001). Five patients (8.1%) had positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test but no abnormal findings on computed tomography. CONCLUSIONS Having an age of more than 24 years was associated with a higher prevalence of pneumomediastinum in COVID-19 patients and emerged as an important risk factor. Multicentre studies with more cases are needed to determine whether pneumomediastinum is associated with additional other risk factors related to COVID-19., Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first detected in Turkey on 11 March 2020.

Case in the paper is of a 24-year-old woman presenting to Baqiyatallah hospital, Tehran, Iran with the occasional fever, weakness, myalgia, fatigue, body aches, and headache who was diagnosed with Coronavirus disease-19 (COVID-19) PCR test. Chest computed tomography (CT) showed spontaneous pneumomediastinum (SPM) and pneumopericardium (SPP). Here, we described SPM, and SPP in a patient with COVID-19, presenting a severe course of the disease.

BACKGROUND: There are limited data regarding the incidence of pneumothorax in COVID-19 patients as well as the impact of the same on patient outcomes. METHODS: A retrospective review of the medical records at three large tertiary care hospitals in Mumbai was performed to identify patients hospitalised with COVID-19 from March 2020 to October 2020. The presence of pneumothorax and/or pneumomediastinum was noted when chest radiographs or CT scans were performed. Demographic and clinical characteristics of patients who developed air leak were recorded. RESULTS: 4,906 patients with COVID-19 were admitted, with 1,324 (27%) having severe COVID-19 disease. The overall incidence of pneumothorax and/or pneumomediastinum in patients with severe disease was 3.2% (42/1,324). Eighteen patients had pneumothorax, 16 had pneumomediastinum and 8 patients had both. Fourteen patients (33.3%) developed this complication breathing spontaneously, 28 patients (66.6%) developed it during mechanical ventilation. Overall mortality in this cohort was 74%, compared with 17% in the COVID-19 patients without pneumothorax (p

Background The use of less invasive surfactant administration (LISA)/minimally invasive surfactant therapy (MIST) has increased due to its potential advantage over traditional surfactant delivery methods through an endotracheal tube. Known complications for this procedure include failure of the first attempt at insertion, desaturation, and bradycardia. To the best of our knowledge, this is the first reported case of pneumomediastinum and subcutaneous emphysema following LISA. Case presentation A preterm newborn born at 27 weeks of gestation presented with respiratory distress syndrome requiring surfactant replacement. LISA using the Hobart method was completed. There was a report of procedural difficulty related to increased resistance to insertion of the 16G angiocath. The newborn was subsequently noted to have subcutaneous emphysema over the anterior aspect of the neck and substantial pneumomediastinum on radiological assessment. Associated complications included hypotension requiring inotropic support. The newborn was successfully managed conservatively, with complete resolution of the air leak. Conclusions Upper airway injury leading to air leak syndrome is a rare complication of the Hobart method for LISA. Awareness of such procedural complications is important as the use of the LISA method increases.

Tracheal and bronchial diverticula are outpouchings arising from the trachea or bronchus. We present a case of a 35-year-old female who presented to the emergency department following a motor vehicle accident and was found to have multiple round, air-filled structures within the mediastinum on computed tomography of the thorax, concerning for pneumomediastinum. The patient had a negative fluoroscopic esophagography and subsequent imaging indicated tracheal and bronchial diverticula. While they are often asymptomatic and incidentally found, tracheal and bronchial diverticula may be misdiagnosed as pneumomediastinum, especially in the setting of blunt or penetrating trauma to the thorax.

Background Boerhaave’s syndrome is the spontaneous rupture of the esophagus, which requires early diagnosis and treatment. Symptoms may vary, and diagnosis can be challenging. Case presentation Case 1: A 54-year-old Chinese man presented to us with sudden-onset epigastric pain radiating to the back following hematemesis. Upper gastrointestinal endoscopy revealed a full-thickness rupture of the esophageal wall. Subsequent computed tomography showed frank pneumomediastinum and heterogeneous pleural effusion. Immediately, esophageal perforation repair operation and jejunostomy were performed. The postoperative period was uneventful, and he was discharged. Case 2: A 62-year-old Chinese man was admitted to the emergency department with thoracic dull pain and chest distress. Chest computed tomography scan showed pneumomediastinum and large left-sided pleural effusion. Esophagus fistula was confirmed by contrast esophagography. Then, we performed thoracotomy to repair the esophageal tear as well as to debride and irrigate the left pleural space. His postoperative period was uneventful, with no leakage or stricture. Case 3: The patient was a 69-year-old Chinese male presenting with severe retrosternal and upper abdominal pain following an episode of forceful vomiting. Thoracic computed tomography scan revealed a rupture in the left distal part of the esophagus, a pneumomediastinum, and left-sided pleural effusions. Conservative treatment failed to improve disease conditions. Open thoracic surgery was performed with debridement and drainage of the mediastinum and the pleural cavity, after which he made a slow but full recovery. Conclusions We highlight that early diagnosis and appropriate surgical treatment are essential for optimum outcome in patients with esophageal rupture. We emphasize the importance of critical care support, particularly in the early stages of management.

Spontaneous pneumomediastinum (SPM), pneumothorax (PNX) and subcutaneous emphysema are rare complications of COVID-19 pneumonia. In this paper we describe 3 cases of COVID-19 pneumonia complicated by SPM with or without PNX. Patient 1 was a 56-year-old woman whose medical history was significant for chronic leukemia. She presented with typical clinical signs of COVID-19 pneumonia and after 2 weeks of hospitalization she developed SPM and subcutaneous emphysema. The management of pneumomediastinum (PNM) was conservative and follow-up computed tomography showed resolution of PNM. Patient 2 was a 67-year-old man presenting with fever, cough and dyspnea. Computed tomography pulmonary angiography was performed after 2 weeks of hospitalization and showed bilateral peripheral consolidations together with massive PNM and right-sided PNX. Thoracic drainage catheter was inserted in his right chest. Despite all supportive care, the patient succumbed to illness. Patient 3 was a 74-year-old man who was admitted to our hospital with COVID-19 pneumonia and spontaneous right-sided PNX. A thoracic drainage catheter was inserted immediately and then removed after ten days which has led to progression of subcutaneous emphysema, PNX and newly diagnosed PNM. Patient was carefully monitored for the next 2 weeks. Follow-up chest x-ray showed regression of PNM and PNX. SPM, PNX and subcutaneous emphysema are rare complications of COVID-19 pneumonia. Increased alveolar pressure and diffuse alveolar injury in severe COVID-19 pneumonia may make the alveoli more prone to rupturing which leads to gas dissemination along the peribronchovascular sheath to the mediastinum. Most cases of SPM and PNX resolve with conservative management.

Foreign body (FBA) in the airway is a common cause of sudden onset of respiratory distress in children. Prompt recognition and early intervention is required to minimize the potentially serious and sometimes fatal consequences.

Background Spontaneous pneumomediastinum (SPM) occurs in cases of mediastinal leaks that are not caused by trauma, mechanical ventilation, or other surgical procedures. In most cases, in the pediatric population a trigger can be identified, most commonly asthma. SPM caused by foreign body aspiration is not a common entity. It is usually a benign condition that generally resolves without severe sequela, but in some cases, severe morbidity and mortality have been documented. Treatment is usually conservative and includes rest, analgesics, and treatment of any underlying pathologies. Case Report We report a case of a 19-month-old boy who presented to the emergency department with acute facial swelling and wheezing with no history of foreign body aspiration. This misleading presentation led the medical staff in the emergency department to initially treat the patient for anaphylaxis. The diagnosis was made only after imaging modalities demonstrated SPM with a suspected foreign body in the right main stem bronchus. Why Should an Emergency Physician Be Aware of This? Providers should consider SPM from an aspirated foreign body in young children with respiratory distress and acute facial swelling, especially when crepitus is present. © 2021 Elsevier Inc.

Background Gastric pneumatosis indicates the presence of air within the stomach wall. The etiologies included gastric ischemia, gastric intramural infection, gastric mucosal disruption, and secondary to pneumomediastinum. Gastric ischemia is rare because of the rich collateral blood supply to the stomach. Case presentation An 82-year-old man presented to the emergency department with a 2-day history of epigastric fullness, following by fever and low blood pressure. Chest X-ray and abdominal computed tomography revealed gastric pneumatosis at the gastric fundus. The esophagogastroduodenoscopy confirmed the ischemic change of mucosa at the gastric fundus. After antibiotics and medical management, the patient became better and was eventually discharged. Conclusion For the diagnosis of gastric ischemia, physicians should be alert to the hints of gastric pneumatosis from X-ray and computed tomography. It is important to distinguish between gastric ischemia and the other causes of gastric pneumatosis to judge clinical management.

OBJECTIVES The incidence of pneumomediastinum (PNMD), its causes of development and its effect on prognosis in the coronavirus disease 2019 (COVID-19) are not clear. METHODS Between March 2020 and December 2020, 427 patients with real-time reverse transcriptase-polymerase chain reaction-confirmed COVID-19 admitted to the intensive care unit were analysed retrospectively. Using receiver operating characteristic analysis, the area under the curve (AUC) for initial invasive mechanical ventilation (MV) variables such as initial peak inspiratory pressure (PIP), PaO2/FiO2 (P/F ratio), tidal volume, compliance and positive end-expiratory pressure was evaluated regarding PNMD development. RESULTS The incidence of PNMD was 5.6% (n = 24). PNMD development rate was 2.7% in non-invasive MV and 6.2% in MV [odds ratio (OR) 2.352, 95% confidence interval (CI) 0.541–10.232; P = 0.400]. In the multivariate analysis, the independent risk factors affecting the development of PNMD were PIP (OR 1.238, 95% CI 1.091–1.378; P, Severe acute respiratory syndrome coronavirus 2, the cause of the coronavirus disease 2019 (COVID-19), is associated with considerable morbidity and mortality [1].

The first cluster of cases of COVID-19 pneumonia was reported on December 31, 2019. Since then, this disease has spread rapidly across the world, and as of September 17, 2021, there are 226,844,344 cases of COVID-19 worldwide with 4,666,334 deaths related to COVID-19. While most COVID-19 cases are mild, some cases are severe with patients developing acute respiratory distress syndrome (ARDS). The pathophysiology of ARDS includes damage to the alveolar epithelium that leads to increased permeability of the alveolar epithelial barrier causing hyaline membrane formation, interstitial edema, and alveolar edema that results in severe hypoxia. Patients with COVID-19 ARDS are supported by non-invasive or invasive mechanical ventilation with an aim to improve oxygenation and maintain adequate blood oxygen levels. Increased intra-alveolar pressure while on mechanical ventilation may lead to alveolar rupture and thus barotrauma-related injuries such as lung tension cysts, pulmonary interstitial emphysema (PIE), pneumomediastinum, pneumopericardium, and pneumothorax. Recent studies have shown that the rate of barotrauma-related events is higher in patients with COVID-19 ARDS compared to patients with ARDS secondary to other etiologies. Radiologists should be aware of the imaging features of COVID-19 ARDS as well as the complications of mechanical ventilation. This educational manuscript will review the features of COVID-19 ARDS, discuss imaging of patients on mechanical ventilation, and review the imaging features of complications related to mechanical ventilation, including ventilator-associated lung injuries.

Subcutaneous emphysema, a known complication of tracheobronchial injury (TBI), is usually a self-limiting condition, but occasionally, a massive one can become life-threatening. We present a patient with TBI who developed massive subcutaneous emphysema with bilateral pneumothorax causing hemodynamic instability. Upon arrival to the hospital, the patient required emergent intubation for impending respiratory collapse. Bilateral thoracostomy tubes were inserted, resulting in hemodynamic improvement. Emergent CT thorax showed a tracheal-oesophageal injury just distal to the cuff of the endotracheal tube (ETT) at the level of the third thoracic vertebra (T3). Despite surgical repair and intensive care, the patient succumbed after a week in ICU due to ventilatory failure. This case report highlights the importance of the initial management of TBI requiring rapid identification and airway management.

Background Pneumomediastium is a rare complication of pregnancy or labor. Methods Here, we report our findings in a case report (gravid 5, para 2, gestational age 33 + 4 weeks) and narratively review the current literature on pneumomediastinum in pregnancy or labor. Results Our case is the first case that experienced pneumomediastinum after relatively limited exposure to barotrauma in the current pregnancy. Other reports describe pneumomediastinum after hyperemesis gravidarum or during labor. Treatment is usually conservatively due to the trauma mechanism of barotrauma to the alveoli. Conclusion Physicians should be aware of the possibility of pneumomediastinum in pregnant women with acute thoracic pain in cases of (previous) hyperemesis gravidarum or during labor.

Air leak syndrome manifesting as pneumomediastinum (PM), pneumothorax (PNX) or subcutaneous emphysema (SCE) has been reported in COVID-19 patients with increasing frequency and with varying outcomes. We report a series of eight cases of PM or SCE from 1 April to May 31, 2021, among COVID-19 patients admitted in our ICU. All the patients had severe hypoxemia (PaO2/FiO2 ratio ?100) and were on noninvasive ventilation when the air leak was detected except one. PM/SCE was observed mostly on the 3 to 5 day after instituting positive pressure ventilation. High respiratory drive with mean tidal volumes in the range of 6 to 10ml/kg predicted body weight was observed in these patients. Mean inspiratory pressure (Pressure support + positive end expiratory pressure) and mean positive end expiratory pressure delivered by the ventilator ranged between 11 to 21 and 5 to 12 cm HO respectively. Outcomes varied with four deaths, four patients requiring intubation, two patients requiring chest drainage and four patients showing overall improvement out of the total eight patients with air leak. Key Messages: 1.Air leak syndrome is not rare in COVID-19 with reported incidence of 10-14%; 2. Spontaneous noninvasive ventilation in patients with high respiratory drive and large fluctuations in tidal volumes seems to be a risk factor for air leak in patients with severe lung involvement; 3. A conservative approach without intercostal drainage seems to be acceptable in the absence of pneumothorax; 4. Prognosis is varied depending on the underlying disease and not always catastrophic. Keywords: Air leak, Pneumomediastinum, COVID­19, Pneumothorax, Subcutaneous emphysema, Noninvasive, Spontaneous ventilation

Spontaneous pneumomediastinum is a rare complication of coronavirus disease 2019. The published literature consists mainly of case reports and small case series. There are still many questions regarding the pathogenesis, the prognostic significance and the implications on patient management. In our hospital, 3 coronavirus disease 2019 patients developed spontaneous pneumomediastinum: 1 on admission at the emergency department and the other 2 during hospitalization. In this study we describe their clinical course and computed tomography (CT) findings. All of them had severe disease according to the total severity score on admission CT. The management of pneumomediastinum was conservative and follow-up CT showed resolution in all patients. As the correlation between extension of parenchymal lung lesions and development of pneumomediastinum is still under investigation, we highlight the importance of reporting the severity score on chest CT in order to obtain more comparable results between different studies. Furthermore, in this tragic circumstance we also had the opportunity to familiarize ourselves with the otherwise uncommon occurrence of air along the bronchovascular sheaths (Macklin effect) and evaluate the ability of CT to detect it.

Rationale: SARS-CoV-2 causing COVID19 has led to a pandemic with over 70 million cases worldwide as well as more than 18 million cases here in the US. Acute Respiratory Distress Syndrome (ARDS) is a severe complication of this disease and traditional ventilation strategies using ARDSNet protocol, including low tidal volumes, appear to cause barotrauma in COVID19 patients at a higher rate than non-COVID19 ARDS patients. The purpose of our retrospective chart review is to identify the incidence of barotrauma in COVID19 patients with ARDS requiring mechanical ventilation here at SJMC. Methods: This study was a retrospective chart review of all patients admitted to critical care units at SJMC with COVID19 infection and requiring mechanical ventilation from March 1, 2020-September 30, 2020. The sample included adult patients (over age 18) with ICD 10 Code for COVID19 (U07.1) and patients who were placed on mechanical ventilation for greater than 24 hours, from March 1, 2020 to September 30, 2020. Both ICD 10 codes and a chart search were utilized to determine which ventilated COVID19 patients developed barotrauma. Results: 140 COVID19 patients underwent mechanical ventilation for greater than 24 hours from March 1, 2020 to September 30, 2020 at our facility. 26 COVID19 patients (18.6%) met our inclusion criteria, developing barotrauma during their hospital admission, of which 25 (17.9%) underwent mechanical (invasive and/or non-invasive) ventilation. The 1 non-ventilated patient was found to have incidental pneumothorax on chest x-ray after a thoracentesis was performed. 80% of the patients were on non-invasive mechanical ventilation prior to intubation and invasive mechanical ventilation. The categorical breakdown of barotrauma was as follows: Pneumothorax 65.4%, subcutaneous emphysema 61.5%, pneumomediastinum 34.6% and pneumoperitoneum 7.7%. None of these patients had any previous history of documented barotrauma. At the time of barotrauma, 15.4% of patients were on NMB drips, 96.2% were on corticosteroids, 42.3% were undergoing proning and 92.3% were on sedation. Prior to the time of barotrauma, 17 patients were on volume control, 7 were on pressure control and 1 was not on mechanical ventilation. Of the 17 patients on volume control, only 1 patient was above the ARDSNet guideline of 6-8 mL/kg IBW. The 7 patients on pressure control had a PEEP ranging from 8 to 15 and a PIP ranging from 25 to 46. Conclusions: Patients with COVID19 who underwent mechanical ventilation developed barotrauma at a higher rate than reported in literature for non-COVID19 patients with ARDS.

From the mere outlook of the ongoing pandemic, coronavirus (severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) seems to target mainly the respiratory system, but more evolving evidence has advocated its multi-organ involvement. While various complications have been reported in coronavirus disease 2019 (COVID-19) patients, spontaneous pneumomediastinum (SP) remains an uncommon complication.

Background: Neonatal pneumomediastinum is seen in 2.5 per 1000 live births and is mostly managed conservatively. An intervention is essential in cases with tension pneumomediastinum. Ultrasonography-guided (USG-guided) relief of pneumomediastinum has been reported in newborns. There are no reported cases of computed tomography-guided (CT-guided) drainage of pneumomediastinum in neonates. Case Presentation: A newborn girl born at 34 weeks of gestation was intubated due to respiratory distress and received intratracheal surfactant treatment. Pneumomediastinum was detected at the chest X-ray on the 6th postnatal hour. On the second postnatal day, the patient's oxygen needs increased, tachypnea and subcostal retractions recurred, so it was decided to intervene. USG-guided drainage of the pneumomediastinum was attempted twice but was unsuccessful. Percutaneous drainage with CT guidance was performed successfully. Conclusion: This report aims to emphasize that CT-guided intervention of pneumomediastinum can be an effective alternative in a newborn if USG-guided intervention fails.

Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.

The new coronavirus (SARS-CoV-2) that arose in 2019 causes a wide spectrum of symptoms and different courses of disease. Pneumothorax, pneumomediastinum and soft tissue emphysema are rare complications in patients with pulmonary involvement. They are the sequelae of severe, virus-induced structural changes of the pulmonary architecture. High pressure artificial ventilation aggravates the problem. Hence pneumothorax and ectopic air in soft tissues are indicators of extensive pulmonary damage. Therefore, efforts should be made to treat even very small or multiply recurrent pneumothorax by drainage procedures.Dass 2019 neu aufgetretene Coronavirus (SARS-CoV-2) bewirkt ein breites Spektrum an Symptomen und Verläufen. Pneumothorax, Pneumomediastinum und Weichteilemphysem sind seltene Komplikationen im Rahmen pulmonaler Beteiligung. Sie entstehen auf Basis der schweren, virusbedingten Lungenveränderungen und werden durch das Erfordernis hoher Beatmungsdrücke aggraviert. Pneumothorax und ektope Luft in Mediastinum und Weichteilen sind damit Indikatoren für gravierende Lungenschäden. Gerade deshalb müssen auch kleine bzw. multipel rekurrierende Pneumothoraxe durch Drainage therapiert werden.

Introduction. Juvenile nasopharyngeal angiofibroma is a rare, benign, well-vascularized tumor of the skull base characterized by destructive growth. The development of endoscopic techniques and experience of surgeons have enabled the removal of this tumor both at early stages and late stages (advanced disease). Patients may develop various complications in the intraoperative and postoperative periods, including massive bleeding, nasal liquorrhea, facial paresthesia, lacrimal hyposecretion, etc. Air penetration into the subcutaneous fat and mediastinum during endoscopic surgery on the paranasal sinuses is rare. Such complication as subcutaneous emphysema and pneumomediastinum after endoscopic endonasal removal of juvenile nasopharyngeal angiofibroma has not been reported in the literature.Case report. A 19-year-old male patient has undergone endoscopic endonasal removal of juvenile nasopharyngeal angiofibroma. The tamponade was removed within the first 24 h postoperatively. Ten hours after it, the patient developed subcutaneous emphysema and pneumomediastinum triggered by sneezing. The diagnosis was confirmed by computed tomography of the neck and chest. The patient was transferred to the intensive care unit and received conservative treatment (including infusion, antibacterial, and antiinflammatory therapy). The symptoms of subcutaneous emphysema and pneumomediastinum subsided in response to treatment. Follow-up examinations (computed tomography and magnetic resonance imaging) confirmed that the tumor had been completely removed. The patient was discharged in a satisfactory condition.Conclusion. Subcutaneous emphysema and pneumomediastinum are exceedingly rare complications of endoscopic endonasal removal of juvenile nasopharyngeal angiofibroma and are caused by anatomical connection between the parapharyngeal / retropharyngeal spaces and mediastinum. To prevent such complications, it is necessary to keep tampons in the nasal cavity for at least 2 days, as well as to instruct patients after surgery (avoid sneezing with their mouth closed, lifting weights, coughing, and vomiting). The nasoseptal flap used to repair the nasopharyngeal defect after tumor removal also ensures its sealing. Patients with complications should undergo computed tomography of the neck and chest (in case of emergency) and should be transferred to an intensive care unit. Conservative treatment (antibacterial and antiinflammatory therapy) will ensure good results in most patients.

We should be aware of the uncommon presentation during the pandemic scenario of the Coronavrus disease 2019 (COVID-19). Pneumothorax, pneumomediastinum, pneumoperitoneum, and massive emphysema subcutis are uncommon complications of COVID-19 Pneumonia. The presence of pneumomediastinum and massive emphysema subcutis were rarely reported in the literature.We present a 69-year-old man with COVID-19 Pneumonia with these complications who were managed conservatively and experienced spontaneous resolution of the complications two weeks later. He was admitted to the intensive care unit and was given a ventilator. Pneumonia, massive emphysema subcutis, pneumomediastinum, and pneumothorax are identified from chest X-ray. An Unenhanced thoraco-abdominal computed tomography Scan revealed the presence of a small pneumoperitoneum. However, a computed tomography scan of the abdomen and pelvis did not show any evidence of bowel perforation. It is necessary to detect these complications earlier, so the management can reduce the associated morbidity and mortality.

Tam Metin / Full Text Tracheal injuries that can lead to life-threatening results are extremely uncommon in children. Although the majority are seen following trauma or invasive procedures, a few paediatric cases exist in the literature of spontaneous tracheal rupture. In the case reported here, a 15-year-old female presented at the Emergency Department with complaints of a sudden onset of chest pain, difficulty breathing, subcutaneous emphysema and pneumomediastinum. On the computed tomography image, a tracheal rupture 8 mm in size was present in the posterior right lateral section. Using a conservative approach, the patient recovered without any complications. If a patient presents with a sudden onset of breathing difficulty following a severe cough accompanied with subcutaneous emphysema in the presence of chest pain, tracheal rupture should be considered. Our patient presents an extremely rare case of tracheal rupture in childhood. The patient recovered completely without complications using a conservative approach. Hayatı tehdit eden sonuçlara yol açabilen trakeal yaralanmalar çocuklarda son derece nadir gözlenir. Çoğunlukla invaziv işlemler ve travma sonrası görülmekle birlikte literatürde çocuklarda çok az sayıda olguda spontan trakeal rüptür bildirilmiştir. Çocuk acil servise ani gelişen solunum güçlüğü ve göğüs ağrısı şikayeti ile başvuran 15 yaşında kız hasta deri altı amfizemi ve pnömomediastinum tespit edildi. Çekilen toraks bilgisayarlı tomografide posterior sağ lateral kesiminde 8 mm boyutunda trakeal rüptür görüldü. Hasta konservatif yaklaşımla komplikasyonsuz iyileşti. Şiddetli öksürük sonrası ani gelişen solunum sıkıntısı, göğüs ağrısı varlığında deri altı amfizem bulguları da eşlik ediyorsa trakeal rüptür mutlaka akla gelmelidir. Çocukluk çağında son derece nadir olması ve konservatif yaklaşımla sorunsuz iyileşmesi nedeniyle bu olguyu sunduk.

Computed tomography for coronavirus infection (COVID-19) is effective not only in making a diagnosis, but also in timely and accurately detecting some complications of this disease in different organs and systems. The paper shows various complications of coronavirus infection that a radiologist may face in practice, which develop both in the natural course and due to therapy for COVID-19, including hemorrhagic and thrombotic events in coagulopathy, pneumothorax, and pneumomediastinum as a result of the direct cytotoxic effect of SARS-CoV-2 on pneumocytes, and barotrauma during mechanical ventilation, as well as pathological fractures due to osteoporosis, including steroid osteoporosis that has developed during therapy with glucocorticosteroids. It considers the main causes and pathogenesis of various complications of coronavirus infection.

SARS COV2 infection can produce pneumothorax and spontaneous pneumomediastinum complications, which are associated with a worse prognosis. Here we present a series of cases of patients who presented subcutaneous emphysema caused by pneumothorax or spontaneous pneumomediastinum during care in the intensive care unit for pneumonia and COVID 19. This group of patients showed, in all cases, prolonged mechanical ventilation, refractory hypoxemia and hypercapnia, acute renal failure, bacterial superinfection, need for broad-spectrum antibiotics, and vasopressor support. Keywords: Subcutaneous Emphysema, Spontaneous Pneumothorax, Spontaneous Pneumomediastinum, COVID 19

Introduction There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the types of air leaks in COVID-19 and their outcomes. Methods The literature search from PubMed, Science Direct, and Google Scholar databases was performed from the start of the pandemic till 31 March 2021. The inclusion criteria were case reports or series on (1) laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, (2) with the individual patient details, and (3) reported diagnosis of one or more air leak syndrome (pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium). Results A total of 105 studies with 188 patients were included in the final analysis. The median age was 56.02 (SD 15.53) years, 80% males, 11% had previous respiratory disease, and 8% were smokers. Severe or critical COVID-19 was present in 50.6% of the patients. Pneumothorax (68%) was the most common type of air leak. Most patients (56.7%) required intervention with lower mortality (29.1% vs. 44.1%, p = 0.07) and intercostal drain (95.9%) was the preferred interventional management. More than half of the patients developed air leak on spontaneous breathing. The mortality was significantly higher in patients who developed air leak with positive pressure ventilation (49%, p Conclusion Air leak in COVID-19 can occur spontaneously without positive pressure ventilation, higher transpulmonary pressures, and other risk factors like previous respiratory disease or smoking. The mortality is significantly higher if associated with positive pressure ventilation and escalation of respiratory support.

Spontaneous pneumomediastinum is a rare complication of viral pneumonia. The prevalence of pneumomediastinum among coronavirus infection patients is unknown.Subjects and methods. Three cases of spontaneous pneumomediastinum among the COVID-19 pneumonia patients were analyzed. The researchers investigated and compared clinical, radiological and laboratory data.Results. According to the research results, no correlation was found between the development of pneumomediastinum and changes in values of blood laboratory tests. As well as there were no signs of correlation between drug treatment and pneumomediastinum frequency.Conclusion: The researchers suggest that the leading cause of spontaneous pneumomediastinum is viral pneumonia-associated severe alveolar damage.

Background Spontaneous pneumomediastinum is characterized by the presence of interstitial air in the mediastinum without any underlying disease. Some cases of spontaneous pneumomediastinum have been reported in the past, although only few reports are available, and its management remains uncertain. This study reviewed our experience in the diagnosis and treatment of spontaneous pneumomediastinum. Methods A retrospective study of 71 cases treated for spontaneous pneumomediastinum at the Yodogawa Christian Hospital between April 2005 and March 2020 was conducted. Results The patients’ mean age was 19.3 years (range, 7–48 years). A triggering event was noted in 69% of the cases. Seventy-six percent of the patients were admitted to the hospital, and 24% were outpatients. Treatment included analgesia, rest, antibiotics, and/or oxygen therapy. Thirty-six patients (51%) were treated with antibiotics. None of the cases presented any complications, including mediastinitis or worsening respiratory condition. Two patients (3%) had a recurrence of spontaneous pneumomediastinum. Conclusions All the patients, with or without antimicrobial treatment and hospitalization, had favorable outcomes. We should therefore reconsider the need for hospitalization and antimicrobial therapy for patients with mediastinitis prophylaxis.

Objective To use a randomized, prospective, multi-institutional study to compare the safety and efficacy of conventional insufflation (CIS) and valveless insufflation (AirSeal Insufflation – AIS) at the conventional pressure of 15 mm Hg in robot-assisted partial nephrectomy – a surgery where AIS has gained popularity for maintaining visualization despite suction. This study was also powered to evaluate the effect of decreasing pneumoperitoneum by 20% in the valveless system. Materials and Methods Three high-volume institutions randomized subjects into CIS 15, AIS 15, and AIS 12 mm Hg cohorts. Endpoints included rates of subcutaneous emphysema (SCE), pneumothorax (PTX), pneumomediastinum (PMS), intraoperative end-tidal carbon dioxide (ET CO2), and peak airway pressure (PAP), as well as hospital stay, post-operative pain, and complications. Given the substantial proportion of retroperitoneal surgery, a secondary analysis evaluated the effect of surgical approach. Results Two hundred and two patients were accrued. SCE was decreased in the AIS 12 mm Hg group (p=0.003). PTX and PMS rates were not statistically significantly different across the 3 insufflation groups. Higher rates of SCE and PMS, although not PTX, were noted in all retroperitoneal surgery groups – with lower SCE rates for AIS 12 mm Hg regardless of surgical approach. Conclusion AIS is often preferred for complex procedures including retroperitoneal and transperitoneal robotic-assisted partial nephrectomy, for its maintenance of pneumoperitoneum despite continuous suction necessary for visualization. This study shows that AIS is safe when compared to CIS at 15 mm Hg, and shows improvement in outcomes when pneumoperitoneum pressure is reduced by 20% to 12 mmHg.

Background Coronavirus disease 2019 (COVID-19) has become a global pandemic and is posing a serious public health problem for almost all countries. Spontaneous pneumomediastinum, a rare condition, is usually seen in patients with underlying pulmonary pathology, infections, or mechanical ventilation. Spontaneous pneumomediastinum is a rare complication in COVID-19 pneumonia. Case presentation We report a case of spontaneous pneumomediastinum, pneumopericardium, and subcutaneous emphysema in a 62-year-old diabetic patient with COVID-19 infection who presented with cough, fever, and breathlessness, which turned to be a fatal complication. Conclusion Pneumomediastinum/subcutaneous emphysema, a not so common complication associated with COVID-19 infection, should be considered as a bad prognostic indicator of worsening disease and hence requires early recognition and careful monitoring of the patient for any possible unfavorable outcome.

Coronavirus infection in most cases is of the type of interstitial pneumonia. According to the literature, the most common complications are thrombotic complications of the lungs, myocardium, central nervous system, liver, and kidneys. There are only isolated reports of pleural complications. The aim. To study the features of the course and term of diagnosis of pleuropulmonary complications, specifying the possibilities of their prevention and exclusion of errors. Materials and methods. Under our supervision, there were 23 patients with various complications of pleuropulmonary character. Among these patients, there were 15 males, 8 – females. There were ten patients under the age of 50 and 13 over the age of 50. The interstitial background in all patients was interstitial changes in the lung parenchyma. Results and discussion. Deterioration of patients (increased temperature, shortness of breath, cough, and decreased blood oxygenation) forced doctors to resort to additional examination and consultation with specialists after a certain period of observation (4–5 days). Pulmonary and pleural hemorrhage occurred in 2 (8,72 %) subjects, spontaneous pneumothorax, including and 1 bilateral, occurred in 5 (21,7 %) patients, pneumohydrothorax – in 4 (14,4 %), pneumomediastinum – in 2 (8,7 %), severe pneumothorax – in 7 (30,4 %) people. The most serious complications were the impression of the pleura with a violation of the integrity of the cortical lungs (pneumohydrothorax, intense pneumothorax), which led to death in 6 (26,1 %) people. The period before the diagnosis of complications was in the range of 4–6 days. Conclusions. Physical control of patients with signs of respiratory failure should be performed every 2 hours, ultrasound – three times a day, examination and lateral radiography – with the duration of shortness of breath more than two days or its increase, without waiting for the time suggested by the radiologist.

The coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2, has resulted in widespread global morbidity and mortality. Herein, we report a case of spontaneous pneumomediastinum and subcutaneous emphysema of the neck and chest wall in a patient hospitalized with respiratory failure due to COVID-19. Since our patient was not treated with mechanical ventilation, this case demonstrates that spontaneous pneumomediastinum can appear in patients with COVID-19 regardless of barotrauma and highlights the pathophysiology of this complication. © 2021 Kipourou M. et al.

Background Dermatomyositis with positive anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody has a distinct phenotype associated with small hand joint arthritis, mucocutaneous ulceration, palmar papules and less muscle involvement. It is also associated with increased risk of rapidly progressive interstitial lung disease (RP-ILD) and has a high mortality rate in adults. There is evidence that cases complicated with spontaneous pneumomediastinum (PNM) have an increase in mortality. While most of the evidence for this rare disease is derived from the adult literature, we report a case diagnosed in an adolescent complicated with both RP-ILD and PNM with a good outcome after aggressive immunosuppressive therapy. Our case also illustrates the potential challenges in diagnosis of this condition in the setting of non-specific clinical manifestations, the need for a high index of suspicion, and the importance of testing for myositis-specific antibodies (MSA) early to aid in diagnosis given the risk of rapid progression in these patients. Case presentation A 16-year-old Chinese female presented with fever and cough for 1 day, and finger swelling for 3 weeks. Physical examination revealed arthritis of fingers and wrists, ulcers and palmar papules over fingers, hyperpigmentation of interphalangeal joints, and rash over the neck. The diagnosis of dermatomyositis was made 1 month later with the onset of malar rash, Gottron’s papules, calcinosis and myalgia. The diagnosis was supported by the presence of anti-MDA5 antibody and evidence of inflammatory myopathy on magnetic resonance imaging. In retrospect, she already had interstitial lung disease at first presentation manifested as cough and opacity on chest radiograph, which was later confirmed with chest computed tomography. She was treated according to adult guidelines with steroid and calcineurin inhibitor. Her disease was resistant to initial therapy and was complicated by RP-ILD and spontaneous PNM. Intensive immunosuppressive therapy including cyclophosphamide and rituximab were required to induce remission. Conclusions Recognition of distinct clinical features of anti-MDA5 antibody-positive dermatomyositis and testing for MSA is crucial in patients with skin ulceration and abnormal pulmonary findings of unknown etiology, as prompt diagnosis with early aggressive treatment and anticipation of complications could make a difference in the outcome of this disease with high mortality.