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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumomediastinum is defined as the presence of free air in the mediastinum&#46; This is a rare manifestation and usually presents spontaneously&#44; as a consequence of injury&#44; rupture of a hollow viscus&#44; or gas-producing infection&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It generally occurs in young adults exposed to a sudden change in intrathoracic pressure that results in the rupture of alveolar septa and alveoli&#44; causing air to escape from the pulmonary interstitial tissue to the peribronchiolar and perivascular tissues of the upper mediastinum and the neck&#46; In clinical practice&#44; it is often the result of precipitating factors such as previous muscle exertion &#40;physical exercise&#44; coughing fit&#44; or asthma attack&#41;&#44; which lead to a Valsalva maneuver or an increase in intrathoracic pressure&#46; In many cases&#44; it is difficult to differentiate spontaneous pneumomediastinum from more subtle causes of secondary pneumomediastinum&#44; such as esophageal perforation&#44; small tears in the central tracheobronchial tree&#44; or lung or mediastinal infections&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The most commonly described symptom is central chest pain&#44; which may radiate to both sides of the chest and the neck&#46; Dyspnea and irritative cough may also appear&#46; Dysphagia&#44; hypernasal speech&#44; and tachycardia are less common&#46; The classic triad of spontaneous pneumomediastinum consists of chest pain&#44; dyspnea&#44; and subcutaneous emphysema&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> However&#44; no symptoms associated with compression of the cervical neurovascular bundle &#40;pupillary changes&#44; loss of visual acuity&#44; headache&#44; etc&#46;&#41; have been described in the literature&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We report the case of a patient with a diagnosis of spontaneous pneumomediastinum associated with anisocoria&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This was a 19-year-old man&#44; with no significant clinical history or known toxic habits&#44; who attended the emergency room due to a 12-h history of cervical neck pain associated with central chest discomfort&#44; and a &#8220;crackling&#8221; sound on palpation of the neck&#46; He reported watery rhinitis in the previous days&#44; and 2 episodes of self-limited vomiting of small amounts of food in the hours prior to presentation in the emergency room&#46; No other symptoms&#44; such as coughing or shortness of breath&#44; were reported&#46; The patient denied a history of trauma in the previous days&#59; he only mentioned that he had resumed his musical activity&#44; playing a wind instrument &#40;cornet&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of note on examination was subcutaneous emphysema in the cervical spine and both supraclavicular fossa&#46; No changes were observed in voice tone and there was no dysphagia&#46; A neurological examination detected significant normoreactive anisocoria &#40;left pupil smaller than the right&#41;&#44; with no changes in visual acuity or ptosis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Complete blood count with serum proteins were normal&#46; Serum biochemistry showed vitamin B<span class="elsevierStyleInf">12</span> levels of 172&#46;1<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; Chest radiograph on admission &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41; showed an area of left paracardiac hyperlucency&#44; consistent with pneumomediastinum&#46; A chest computed tomography &#40;CT&#41; was performed to confirm the diagnosis and to complete the study&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">On computed tomography &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; the most significant findings were a large pneumomediastinum that dissected the mediastinal structures and extended along the left oblique fissure&#46; It was also accompanied by subcutaneous emphysema in both laterocervical regions&#44; the supraclavicular fossa &#40;predominantly in the left side&#41;&#44; and both axillary regions&#46; Neither pneumothorax nor rib fractures were observed&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the patient&#39;s stable status&#44; he was admitted to the general hospital ward&#44; under the care of the pulmonology staff&#46; A clinical judgment of spontaneous pneumomediastinum was made&#44; although the contribution of factors associated with Valsalva maneuvers or barotrauma could not be ruled out&#46; Conservative treatment was administered&#44; with oxygen therapy&#44; rest&#44; and analgesia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">During the hospital stay&#44; evaluation by the neurologist was requested&#44; since anisocoria is not described in the literature as a symptom associated with pneumomediastinum &#40;except in cases of cervical spine injuries in which the sympathetic nervous system is affected&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The neurological study was completed with head CT&#44; cranial artery angio-MRI &#40;circle of Willis&#41;&#44; and echo-Doppler of the supra-aortic trunks&#44; all of which were normal&#46; We concluded that the anisocoria was associated with altered sympathetic and vagal modulation in the setting of pneumomediastinum with secondary compression of nerve structures by associated subcutaneous emphysema&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient was also assessed by hospital&#39;s ENT specialist&#44; and no changes were found on fiberoptic naso-laryngoscope&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was discharged 7 days after admission&#44; with a chest X-ray showing no signs of pneumomediastinum and full reabsorption of subcutaneous emphysema&#46; Anisocoria resolved progressively during the stay&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The course of spontaneous pneumomediastinum is benign in most cases&#44; and observation and conservative treatment are sufficient for recovery&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The risk of recurrence is very low&#46; Secondary causes that&#44; if not promptly diagnosed&#44; might occasion an unfavorable clinical course should be excluded&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> including cervical spine injuries and&#47;or contusions&#44; vascular aneurysms&#44; and esophageal perforation&#46; Diagnosis requires a high level of suspicion&#44; given the scant or unclear clinical manifestations&#59; up to one third of patients do not present any precipitating factor&#44; and subtle changes in the chest X-ray may go unnoticed&#46; Given our experience&#44; it may also be of interest to evaluate concomitant neurological changes&#46; Though not reported in the literature&#44; these may contribute to the differential diagnosis of this entity&#44; and moreover&#44; require a full assessment to rule out more severe clinical syndromes that can compromise the cervical sympathetic nervous system&#46;</p></span>"
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Scientific Letter
Anisocoria Associated With Spontaneous Pneumomediastinum
Anisocoria como síntoma asociado a neumomediastino espontáneo
Lidia López Lópeza,
Corresponding author
lydia.lopezlopez@gmail.com

Corresponding author.
, Alba Ramírez Buenob, Anneli Kubarseppc
a Servicio de Neumología, Hospital Vithas Xanit Internacional, Málaga, Spain
b Servicio de Medicina Interna, Hospital Vithas Xanit Internacional, Málaga, Spain
c Servicio de Neurología, Hospital Vithas Xanit Internacional, Málaga, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Chest X-ray&#44; showing &#40;arrows&#41; signs of subcutaneous emphysema the right laterocervical region and an area of left paracardiac hyperlucency&#44; suggestive of pneumomediastinum&#46; &#40;B&#41; Chest CT &#40;parenchymal window&#41; showing extensive pneumomediastinum in several regions&#44; dissecting the mediastinal structures&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumomediastinum is defined as the presence of free air in the mediastinum&#46; This is a rare manifestation and usually presents spontaneously&#44; as a consequence of injury&#44; rupture of a hollow viscus&#44; or gas-producing infection&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It generally occurs in young adults exposed to a sudden change in intrathoracic pressure that results in the rupture of alveolar septa and alveoli&#44; causing air to escape from the pulmonary interstitial tissue to the peribronchiolar and perivascular tissues of the upper mediastinum and the neck&#46; In clinical practice&#44; it is often the result of precipitating factors such as previous muscle exertion &#40;physical exercise&#44; coughing fit&#44; or asthma attack&#41;&#44; which lead to a Valsalva maneuver or an increase in intrathoracic pressure&#46; In many cases&#44; it is difficult to differentiate spontaneous pneumomediastinum from more subtle causes of secondary pneumomediastinum&#44; such as esophageal perforation&#44; small tears in the central tracheobronchial tree&#44; or lung or mediastinal infections&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The most commonly described symptom is central chest pain&#44; which may radiate to both sides of the chest and the neck&#46; Dyspnea and irritative cough may also appear&#46; Dysphagia&#44; hypernasal speech&#44; and tachycardia are less common&#46; The classic triad of spontaneous pneumomediastinum consists of chest pain&#44; dyspnea&#44; and subcutaneous emphysema&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> However&#44; no symptoms associated with compression of the cervical neurovascular bundle &#40;pupillary changes&#44; loss of visual acuity&#44; headache&#44; etc&#46;&#41; have been described in the literature&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We report the case of a patient with a diagnosis of spontaneous pneumomediastinum associated with anisocoria&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This was a 19-year-old man&#44; with no significant clinical history or known toxic habits&#44; who attended the emergency room due to a 12-h history of cervical neck pain associated with central chest discomfort&#44; and a &#8220;crackling&#8221; sound on palpation of the neck&#46; He reported watery rhinitis in the previous days&#44; and 2 episodes of self-limited vomiting of small amounts of food in the hours prior to presentation in the emergency room&#46; No other symptoms&#44; such as coughing or shortness of breath&#44; were reported&#46; The patient denied a history of trauma in the previous days&#59; he only mentioned that he had resumed his musical activity&#44; playing a wind instrument &#40;cornet&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of note on examination was subcutaneous emphysema in the cervical spine and both supraclavicular fossa&#46; No changes were observed in voice tone and there was no dysphagia&#46; A neurological examination detected significant normoreactive anisocoria &#40;left pupil smaller than the right&#41;&#44; with no changes in visual acuity or ptosis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Complete blood count with serum proteins were normal&#46; Serum biochemistry showed vitamin B<span class="elsevierStyleInf">12</span> levels of 172&#46;1<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; Chest radiograph on admission &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41; showed an area of left paracardiac hyperlucency&#44; consistent with pneumomediastinum&#46; A chest computed tomography &#40;CT&#41; was performed to confirm the diagnosis and to complete the study&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">On computed tomography &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; the most significant findings were a large pneumomediastinum that dissected the mediastinal structures and extended along the left oblique fissure&#46; It was also accompanied by subcutaneous emphysema in both laterocervical regions&#44; the supraclavicular fossa &#40;predominantly in the left side&#41;&#44; and both axillary regions&#46; Neither pneumothorax nor rib fractures were observed&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the patient&#39;s stable status&#44; he was admitted to the general hospital ward&#44; under the care of the pulmonology staff&#46; A clinical judgment of spontaneous pneumomediastinum was made&#44; although the contribution of factors associated with Valsalva maneuvers or barotrauma could not be ruled out&#46; Conservative treatment was administered&#44; with oxygen therapy&#44; rest&#44; and analgesia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">During the hospital stay&#44; evaluation by the neurologist was requested&#44; since anisocoria is not described in the literature as a symptom associated with pneumomediastinum &#40;except in cases of cervical spine injuries in which the sympathetic nervous system is affected&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The neurological study was completed with head CT&#44; cranial artery angio-MRI &#40;circle of Willis&#41;&#44; and echo-Doppler of the supra-aortic trunks&#44; all of which were normal&#46; We concluded that the anisocoria was associated with altered sympathetic and vagal modulation in the setting of pneumomediastinum with secondary compression of nerve structures by associated subcutaneous emphysema&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient was also assessed by hospital&#39;s ENT specialist&#44; and no changes were found on fiberoptic naso-laryngoscope&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was discharged 7 days after admission&#44; with a chest X-ray showing no signs of pneumomediastinum and full reabsorption of subcutaneous emphysema&#46; Anisocoria resolved progressively during the stay&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The course of spontaneous pneumomediastinum is benign in most cases&#44; and observation and conservative treatment are sufficient for recovery&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The risk of recurrence is very low&#46; Secondary causes that&#44; if not promptly diagnosed&#44; might occasion an unfavorable clinical course should be excluded&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> including cervical spine injuries and&#47;or contusions&#44; vascular aneurysms&#44; and esophageal perforation&#46; Diagnosis requires a high level of suspicion&#44; given the scant or unclear clinical manifestations&#59; up to one third of patients do not present any precipitating factor&#44; and subtle changes in the chest X-ray may go unnoticed&#46; Given our experience&#44; it may also be of interest to evaluate concomitant neurological changes&#46; Though not reported in the literature&#44; these may contribute to the differential diagnosis of this entity&#44; and moreover&#44; require a full assessment to rule out more severe clinical syndromes that can compromise the cervical sympathetic nervous system&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez LL&#44; Bueno AR&#44; Kubarsepp A&#46; Anisocoria como s&#237;ntoma asociado a neumomediastino espont&#225;neo&#46; Arch Bronconeumol&#46; 2018&#59;54&#58;437&#8211;439&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Chest X-ray&#44; showing &#40;arrows&#41; signs of subcutaneous emphysema the right laterocervical region and an area of left paracardiac hyperlucency&#44; suggestive of pneumomediastinum&#46; &#40;B&#41; Chest CT &#40;parenchymal window&#41; showing extensive pneumomediastinum in several regions&#44; dissecting the mediastinal structures&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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