A 35-year-old woman presented to the emergency department (ED) with vague abdominal complaints. The patient had a complex medical history that included diverticulosis and relapsing polychondritis. Initially, her polychondritis was limited to involvement of the ears and nose. Within the past few years, however, her polychondritis flares had been associated with progressive dyspnea, which prompted intermittent and then long-term use of high-dose oral corticosteroids.
Despite the addition of methotrexate and cyclosporine, the patient continued to experience progressive dyspnea and hoarseness. This prompted a formal chest CT evaluation to assess for airway involvement, which was done shortly before her presentation to the ED. Although there was no evidence of airway involvement associated with relapsing polychondritis, the CT scan demonstrated pneumomediastinum, an unsuspected finding of uncertain etiology (Figure 1).
Because of her progressive abdominal symptoms, the patient was immediately referred to the ED. On physical examination, her blood pressure was 110/80 mm Hg and her heart rate and respiration rate were normal. Her oxygen saturation on room air was 97%. She had no palpable crepitus. Her lungs were clear to auscultation and percussion, without wheezes, rhonchi, or rales. Heart sounds were normal with no murmur, rub, or gallop.
The patient's abdomen was focally tender in the left lower quadrant with shake and rebound tenderness, and there was a suggestion of a firm collection in the left lower quadrant. Bowel sounds were normal. The rest of her physical examination was unremarkable.
Laboratory data were remarkable for an elevated white blood cell count (23,000/µL, with a differential of 91% neutrophils, without bandemia). Her hematocrit value was 33%, and platelet count was 473,000/µL. The lactate dehydrogenase level was normal at 191 U/L. Her erythrocyte sedimentation rate was elevated at 66 mm/h, antineutrophilic cytoplasmic antibody test results were negative, and C-reactive protein level was 83 mg/L.
A chest radiograph was obtained for further assessment and is shown left (Figure 2).
How would you interpret these findings?
How would you proceed?
1. Warshaw AL, Welch JP, Ottinger LW. Acute perforation of the colon associated with chronic corticosteroid therapy. Am J Surg. 1976;131:442-446.
2. Mpofu S, Mpofu CM, Hutchinson D, et al. Steroids, non-steroidal anti-inflammatory drugs, and sigmoid diverticular abscess perforation in rheumatic conditions. Ann Rheum Dis. 2004;63:588-590.
3. Morris CR, Harvey IM, Stebbings WS, et al. Anti-inflammatory drugs, analgesics and the risk of perforated colonic diverticular disease. Br J Surg. 2003;90:1267-1272.
4. ReMine SG, McIlrath DC. Bowel perforation in steroid-treated patients. Ann Surg. 1980;192:581-586.
5. Weiner HL, Rezai AR, Cooper PR. Sigmoid diverticular perforation in neurosurgical patients receiving high-dose corticosteroids. Neurosurgery. 1993;33:40-43.