A 38-year-old woman with a history of injection drug use presented with progressive pain in the left arm and neck and fever (temperature, up to 38.8°C [102°F]) of 9 days' duration. Physical findings included subcutaneous crepitus, erythema, and swelling of the left arm, chest, and neck. White blood cell count was 27,000/µL with 91% neutrophils. Chest radiographs showed gas in the subcutaneous and soft tissue of the neck, arm, and chest . Necrotizing fasciitis was suspected.
A 47-year-old woman with cutaneous T-cell lymphoma was evaluated for swelling of the left side of the chest and neck that developed several hours after a chest tube was removed. The tube had been placed during video- assisted thoracoscopy 5 days earlier. At that time, severe necrotizing Cytomegalovirus pneumonia was diagnosed, and intravenous fluids via a left-sided triple-lumen subclavian catheter were started. The catheter was removed after a nurse noticed the swelling.
Blood pressure was 126/77 mm Hg; heart rate, 88 beats per minute; respiration rate, 14 breaths per minute; and PO2, 97% while breathing through a nasal cannula. The chest was clear to auscultation and equally resonant to percussion bilaterally. However, the left breast and soft tissues of left chest and neck were disproportionately larger than the right-sided structures. On palpation of the affected tissues, "bubble wrap" crackles were felt. Subcutaneous emphysema from a small pneumothorax on the left border of the heart was confirmed by a chest radiograph.
Small pneumothoraces are a common complication of thoracic surgical procedures. Subcutaneous emphysema may occur when the pleura is broken and the air tracks through the tissue planes until it reaches the skin. A small pneumothorax with subcutaneous emphysema usually resolves as the air is slowly reabsorbed-provided the leak that produces the pneumothorax seals spontaneously.
The patient was monitored with serial physical examinations and chest radiographs for 48 hours. She was discharged to a rehabilitation facility several days later without further complication.