Subcutaneous Emphysema of the Axilla, Chest Wall, Mediastinum, Retroperitoneum and Spinal Canal in a Patient with Cannabis Hyperemesis Syndrome

Abstract

Aim: We describe the clinical history of a young adult male who presented with repeated episodes of emesis and subcutaneous emphysema in the context of frequent cannabis use. Case Presentation: A 20-year-old male presented with a ten-day history of vomiting of up to forty times per day. He had experienced frequent episodes in the past but had never sought medical care. His vomiting was accompanied by subjective fever, chills, and severe nausea limiting his ability to take in food and liquids. Several days prior to presentation, he noticed “rice crispy” crackling under the skin of his neck and chest. His social history was notable for daily marijuana use. Laboratory tests were remarkable for low levels of sodium (129 meq/L; normal 135-145), potassium (2.5 meq/L; normal 3.5-5.0), and chloride (77 meq/L; normal 96-106) as well as elevated bicarbonate (CO2) (40 meq/L; normal 20-24). Computed tomography (CT) with intravenous (IV) contrast of the neck, chest, abdomen and pelvis revealed extensive subcutaneous emphysema throughout the supraclavicular, axillary, and bilateral anterior/posterior chest walls which track down into the mediastinum, retroperitoneum, abdomen, lower back, and upper thoracic spinal canal (Figs. 1-4). No significant pneumothorax was present. A barium swallow study yielded no evidence of an esophageal perforation. Conclusion: We present a case of extensive subcutaneous emphysema secondary to rupture of a peripheral airway from forceful vomiting secondary to cannabis hyperemesis syndrome.