Vomiting to Arrest: A 37-Year-Old's Bizarre Diagnosis

Medscape

3 days ago

A 37-year-old man with a history of Roux-en-Y gastric bypass and chronic alcohol use was found collapsed at home after a possible 48-hour period.
Shortly after initial mobilisation by emergency responders, he developed sudden cardiac arrest, with return of spontaneous circulation achieved within 2 minutes.
Following transport and hospital admission, the patient remained hypotensive and required ICU admission with mechanical ventilation.
A whole-body CT scan performed during transfer from the emergency department to the ICU revealed extensive air in the epidural space extending from the cervical to thoracic spine, along with pneumomediastinum surrounding the great vessels. No pneumothorax or free fluid was noted.
The case reported by Jérôme Dehon, MD, a resident physician in emergency medicine and critical care, and colleagues at the Université Catholique de Louvain in Brussels, Belgium, documents a rare and dramatic clinical condition.
The Patient and His History
The patient was brought to the emergency department after being found collapsed at home, with a possible 48-hour delay before the discovery.
Shortly after the initial mobilisation by the emergency responders, he experienced a sudden cardiac arrest. Cardiopulmonary resuscitation was initiated immediately, and return of spontaneous circulation was achieved within 2 minutes after a single dose of intravenous epinephrine.
Despite fluid resuscitation, the patient remained hypotensive after admission to the emergency department and was transferred to the ICU for vasopressor support and further evaluation.
He was sedated, intubated, and mechanically ventilated, and his recent postcardiac arrest status further limited the possibility of a reliable neurologic assessment.
Findings and Diagnosis
The patient's vital signs were continuously monitored. A whole-body CT scan performed during the transfer from the emergency department to the ICU revealed extensive air in the epidural space from the cervical to thoracic spine, along with pneumomediastinum surrounding the great vessels in the absence of pneumothorax or free fluid.
Collateral history from the patient's family revealed multiple episodes of severe vomiting in the days before presentation.
Given the patient's surgical history and radiologic findings, an oesophageal perforation was initially suspected. An upper endoscopy was performed but showed no evidence of a significant fistula or visible perforation.
After sedation was weaned, neurologic examination revealed no focal deficits. Transient vertical nystagmus was observed and resolved following empirical thiamine supplementation.
Although a brain MRI performed 2 weeks later showed no structural abnormalities suggestive of Wernicke encephalopathy, the clinical response supported this working diagnosis in the context of prior bariatric surgery and chronic alcohol use.
The patient's clinical status improved steadily with supportive treatment. Follow-up CT imaging showed complete resolution of both pneumomediastinum and pneumorachis.
Alveolar barotrauma secondary to repeated vomiting was considered the most likely cause, resulting in air dissection into the mediastinum and epidural space.
Discussion
Spontaneous pneumorachis, defined as the presence of air in the spinal canal without trauma or recent instrumentation, is an exceptionally rare entity. Reliable epidemiologic data on its frequency in Germany are lacking, but it is considered exceedingly rare. This case report 'serves as a reminder that while the Macklin effect offers a plausible mechanism for air dissection into the epidural space, potentially life-threatening conditions such as oesophageal rupture must always be actively excluded. The striking radiological findings initially raised concerns regarding life-threatening pathology; however, the clinical course proved benign under conservative management. The case reminds us that dramatic imaging should not overshadow clinical reasoning and that management must remain rooted in structured, evidence-based assessment,' the author concluded.