Case presentation

A 75-year-old man was admitted to the cardiac care unit because of congestive heart failure (CHF) secondary to non-ST elevated myocardial infarction (NSTEMI). His medical history included CHF, hypertension, diabetes, bronchial asthma, and hyperuricemia. He denied any past surgical interventions. At admission, the patient was intubated and underwent percutaneous coronary angioplasty (PCA). His hospital course was complicated with refractory respiratory failure due to pulmonary edema, pneumonia, and bronchial asthma. He was intubated three times in 18 days. Steroids used to treat his asthma included intravenous methylprednisolone 40 mg for 3 days, which was switched to oral prednisone 30 mg, tapering to 5 mg over 12 days. Ceftriaxone was administered on hospital days 4–11 to treat pneumonia.

He was finally extubated on hospital day 18, at which time routine chest radiography showed pneumomediastinum, subcutaneous emphysema, and subdiaphragmatic free air (figure 1). He was afebrile and his vital signs were normal except for mild tachycardia (heart rate 105 bpm). He presented with abdominal bloating but denied abdominal pain. He exhibited crepitation all over his body. His abdomen was distended and soft. His white cell count was 1.21x10∧9/L, blood urea nitrogen 89.6 mg/dL, and creatinine 4.35 mg/dL. Non-contrast CT showed extensive subcutaneous emphysema over the chest and abdominal wall, pneumomediastinum without pneumothorax, massive pneumoperitoneum, and pneumoretroperitoneum. Diffuse mesenteric emphysema was observed without ascites (figure 2). The acute care surgery service was consulted.