Pediatric Pulmonology 43:604–606 (2008)

Case Report

Acute Dyspnea in an Adolescent Girl After PhysicalExertion: A Case Report and Review of the Literature

Ebru Yalcın, MD1* and Macit Arıyurek, MD

2{

Summary. Dyspnea is a common symptom of cardiac and pulmonary diseases. We present a

15-year-old girl with acute dyspnea, chest pain, cough, and difficulty in swallowing whose initial

diagnosis was psychogenic dyspnea. The etiology of acute dyspnea is discussed and reported

cases are reviewed in thiscase report. Pediatr Pulmonol. 2008; 43:604–606. �2008Wiley-Liss, Inc.

Key words: dyspnea; children; etiology; pneumomediastinum.

INTRODUCTION

Dyspnea (acute shortness of breath) is a commonsymptom of cardiac and pulmonary diseases.1 Promptdiagnosis of the underlying disease is very important toensure the initiation of appropriate therapeutic measures.In most cases the diagnosis can be suspected from anaccurate history and thorough clinical work-up, and can beconfirmed by additional diagnostic procedures.2 Possibleetiologies of dyspnea can be classified as obstructiveor restrictive pulmonary disorders, pulmonary vasculardiseases (pulmonary embolism), and cardiac problemsleading to myocardial dysfunction.1–3 Other causes maybe acute upper airway obstruction, metabolic acidosis, aneuromuscular condition, or psychogenic disorders.3

Adolescents that present with unexplained respiratorysymptoms may be suffering from some form of psycho-somatic illness.4 Psychogenic dyspnea is uncommon, butmust be considered when organic causes have been ruledout and patient social history is suggestive, especially inadolescents.

CASE REPORT

A 15-year-old girl presented to our hospital with a 1-dayhistory of dyspnea, chest tightness, cough, and slightdifficulty in swallowing. She also described retrosternalchest pain. She had no history of asthma, foreign bodyaspiration, or trauma. She was previously diagnosedwith psychogenic dyspnea at another hospital and wasprescribed diazepam. Physical examination revealedbilateral diminished breath sounds. Postero-anterior andlateral chest radiographs (Fig. 1), EKG, pulmonary

function tests, and oxygen saturation level were normal.After rechecking the patient’s history it was learnedthat she has been playing volleyball at school for 5 years.She most recently played 2 days earlier, but did notremember any drastic event. High-resolution com-puterized tomography (HRCT) revealed the appearanceof pneumomediastinum (Fig. 2). The patient was closelymonitored, oxygen was administered to facilitate theabsorption of the mediastinal air, and she was advised torest and avoid movements that would create forcedexpiration. A few days later her symptoms completelyresolved, and after a couple of months, she again playedvolleyball with her team without the recurrence ofpneumomediastinum.

1Hacettepe University Faculty of Medicine, Chest Diseases Unit, Depart-

ment of Pediatrics, Ankara, Turkey.

2Hacettepe University Faculty of Medicine, Department of Radiology,

Ankara, Turkey.

{Professor.

*Correspondence to: Ebru Yalcın, MD, Associate Professor of Pediatrics,

Hacettepe University Faculty of Medicine, Pediatric Chest Diseases Unit,

06100 Ankara, Turkey. E-mail: ebruy@hacettepe.edu.tr

Received 7 January 2008; Revised 28 January 2008; Accepted 31 January

2008.

DOI 10.1002/ppul.20803

Published online in Wiley InterScience

(www.interscience.wiley.com).

� 2008 Wiley-Liss, Inc.

DISCUSSION

Spontaneous pneumomediastinum (SP) is charac-terized by the presence of interstitial air in themediastinum without any apparent precipitatingfactor, such as trauma, tracheobronchial or esophagealperforation, or surgery. The sudden increase in intra-alveolar pressure is usually initiated by coughing orexpiration against a closed glottis. It occurs when thealveoli surrounding a blood vessel rupture, allowing air toescape the lungs and travel along the vessels and bronchito the mediastinum.5 Pneumomediastinum in association

with athletic exertion had been reported exclusively inhealthy young males; however, Pierce et al.5 were the firstto report a female case, a 24-year-old track and fieldathlete. Unlike our patient, Pierce et al.’s had sub-cutaneous emphysema and chest X-ray showed pneumo-mediastinum. The diagnosis of pneumomediastinum canbe made based on certain symptoms (acute chest pain,dyspnea), and clinical (Hamman’s sign with auscultationand crepitus in the neck soft tissue) and radiologicalfindings (radiolucent line around the cardiac border onpostero-anterior chest radiographs or mediastinal airmay also outline the aorta).6,7 Although our patient wassymptomatic, her physical examination and chest X-raygave no clues about the diagnosis and SP could onlybe detected with HRCT. Mihos et al.7 retrospectivelyreviewed 10 patients (9 male, 1 female) with sports-relatedSP; only 1 patient played volleyball, 4 participatedin scuba diving, 2 played basketball, and 3 played soccer.In their series, retrosternal chest pain was the mostcommon symptom (90%), and subcutaneous emphysemaand Hamman’s sign were the most common physicalfindings (90%). The diagnosis of pneumomediastinumwas established in all patients by chest radiographies thatshowed free mediastinal air. All the patients were treatedconservatively and only one case had a recurrence of SP.Finally, Macia et al.8 published 41 cases with SP whosechest radiographs were consistent with pneumomediasti-num. There are three main approaches to the treatment ofSP: rest, oxygen therapy, and analgesia. These therapyapproaches, along with the restriction of athletic activity,

Fig. 1. Normal postero-anterior and lateral chest radiographs of the patient.

Fig. 2. Appearance of pneumomediastinum in high resolution

computer tomography scan.

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were used with our patient. Generally, SP is a benigncondition that resolves, if recommendations are followed,within 3–15 days.7

In the presented case, we described a girl with SP thatdid not have the classical physical examination findingsand had a normal-looking chest X-ray. To the best of ourknowledge this is the first case reported with such features.

Based on our experience with this case, pneumo-mediastinum is possible in the athletic population andshould be considered when assessing patients with suddendyspnea and retrosternal chest pain, even when they havenormal findings and chest X-ray. When chest roentgeno-gram findings are inconclusive, CT appears to benecessary to establish pneumomediastinum; otherwise,misdiagnosis would be inevitable.

Clinicians must be aware of this entity before diagnos-ing psychogenic dyspnea because rapid assessment anddiagnosis are necessary to prevent possible severecomplications.

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