Spontaneous subcutaneous emphysema in a male toddler in a health facility in Nasarawa state: A case report

INTRODUCTION

Spontaneous subcutaneous emphysema (SSE) is the presence of gas or air beneath the skin is characterized by swelling of the affected body part.^[1] The characteristic feelings of air under the skin (crepitus) is an important sign of the disease entity.^[2] Subcutaneous emphysema is a complication of various medical conditions such as pneumonia, pertussis, bronchial asthma, foreign body aspiration, blunt and penetrating injury, post-thoracostomy, positive pressure ventilation, and oxygen administration.^[3-6] However, it is a rare condition in children and requires a high index of suspicion to diagnose. The management is largely conservative and patients often recover without sequelae.^[5,6]

The swelling can involve a different part of the body notably the chest, neck, scalp, trunk, and the upper limbs depending on the pathology and its severity.^[5,7-9] Coexistence of subcutaneous emphysema with pneumothorax or pneumomediastinum is more common in patients with acute exacerbation of bronchial asthma.^[7,8] In addition, pneumothorax rarely complicates pneumonia among immunocompetent children.^[10] In this report, we describe a rare occurrence of extensive subcutaneous emphysema associated with pneumothorax in an 18-month immunocompetent toddler who was conservatively managed.

CASE REPORT

The case is an 18-month-old male toddler who was brought to our emergency pediatric unit by his mother on account of progressive body swelling of 5 days duration. The swelling was said to be gradual, started from the left subauricular region, and gradually progressed to involve the face, upper parts of the trunk, and the upper limbs.

The swelling was noticed 2 days into admission at a peripheral hospital where he was being managed for bronchopneumonia. He had presented in the facility with 2 days history of high fever, non-paroxysmal cough, and breathing difficulty. He received parenteral amoxicillin-clavulanate, intravenous fluid, and high-flow nasal cannula oxygen therapy before referral to our unit. There was no history of chest trauma or airway instrumentation, no personal and family history of asthma, or foreign body aspiration. He was exclusively breastfed and fully immunized. His growth and developmental milestones had been satisfactory and he weighed 11 kg at presentation which was normal for his age.

Examination revealed a conscious, anxious, and irritable (but consolable) child with obvious superficial swelling of the face, scalp, the neck, both upper limbs, and the trunk [Figure 1]. There was crepitus on palpation of the swelling but no signs of inflammation. He was not febrile, not jaundiced, or cyanosed and he was well hydrated. He had a normal respiratory rate with optimal oxygen saturation. There were widespread crepitations but resonant percussion notes. Other systemic examinations were normal.

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Figure 1:

Clinical manifestations at the time of admission.

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An assessment of bronchopneumonia complicated by extensive subcutaneous emphysema was made. He was commenced on intravenous Gentamycin in addition to Amoxicillin-Clavulanate and was also administered an anxiolytic (chlorpheniramine).

Results of complete blood count and serum electrolytes were all within normal limits. His HIV screening was negative and blood culture yielded no growth. A babygram [Figure 2] and skull X-ray [Figure 3] of the child showed streaky areas of lucency under the skin of the scalp, neck, trunk, and upper limbs with right-sided pneumothorax.

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Figure 2:

Babygram showing air trapping under the skin of skull, neck and thorax.

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Figure 3:

CXR showing minimal pneumothorax.

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Resolution of emphysema was noticeable on the 3^rd day of admission and was completed by the 5^th day. The baby’s vital signs remained stable, abnormal chest signs also resolved and the child was subsequently discharged after 7 days of hospitalization. The baby has been seen thrice on follow-up and has been healthy.

DISCUSSION

Subcutaneous emphysema results from processes allowing free air to enter into the subcutaneous tissue.^[1] It is most commonly caused by pneumomediastinum or pneumothorax but rarely, air may be formed in the subcutaneous tissues by gas-forming bacteria.^[1] The primary diagnosis of the index case is pneumonia, which was complicated by SSE and pneumothorax. This is consistent with the report by Okposio and Unior at a Central Hospital in Delta State.^[11]

Therapeutic response to antibiotics would suggest a bacterial etiology of pneumonia in the highlighted case, although the full blood count was normal and blood culture was negative for any bacterial pathogen. This is consistent with earlier reports.^[3,7] Okposio and Unior,^[11] however, found elevated white cell count in their report. The index case had received 5 days of antibiotics before presentation with resolved pyrexia and this may have accounted for the absence of leukocytosis and negative blood culture.

The extensiveness of subcutaneous emphysema, in this case, is similar to the reports from a retrospective review by Abril and Ocete^[9] in Granada, Spain, and this is due to the continuum of fascia plane across the body. The evolution of the emphysema could also have been aggravated by the high-flow nasal cannula (HFNC) oxygen therapy he had received from the referral health facility. Although HFNC is a safe method of effective oxygen delivery in children, it could be complicated by barotrauma such as pneumothorax and pneumomediastinum.^[12]

Mild anxiolytic was administered to the patient to minimize the anxiety and restlessness (manifesting as excessive crying) as these could increase airway pressure and worsen emphysema.^[5,9] The patient recovered fully on conservative care and was discharged on the 7^th day on admission. This is similar to earlier reports by Siddki and Agrawad^[13] in the United Kingdom, Akinyemi et al.^[7] and Okposio and Unior^[11] in Abeokuta and Delta in Nigeria, respectively. However, Aliyu^[5] in Kano Nigeria discharged after 2 weeks on admission due to prolong oxygen therapy reflecting the severity of the underlying disease.

CONCLUSION

SSE associated with pneumothorax is a rare complication of childhood pneumonia but should be anticipated among subjects receiving high-flow oxygen therapy. Management is largely conservative and directed toward the cause.