S1997 Spontaneous Pneumomediastinum Secondary to Cannabinoid Hyperemesis Syndrome

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INTRODUCTION: Marijuana use has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum, a rare condition characterized by free air in the mediastinum not preceded by medical or surgical trauma. We present the case of cannabinoid hyperemesis syndrome causing spontaneous pneumomediastinum. CASE DESCRIPTION/METHODS: A 23-year-old female with a history of cannabinoid hyperemesis syndrome presented to the emergency room with a 3-day history of chest pain associated with nausea and multiple episodes of vomiting. She confirmed a three-year history of daily inhaled marijuana use. A CT Chest revealed extensive pneumomediastinum with air tracking along the left hilum/bronchovascular sheath of an unclear source with no radiographic evidence of chest trauma. The patient was admitted to the intensive care unit for continued management. Subsequent water-soluble contrast esophageal revealed findings consistent with pneumomediastinum and no evidence of esophageal perforation, hence Boerhaave’s syndrome was excluded. Given her recurring cyclic vomiting in the setting of cannabis the patient was diagnosed with cannabinoid hyperemesis syndrome (CHS) with spontaneous pneumomediastinum. The patient was managed conservatively, with complete recovery and extensively counseled on cannabis cessation. DISCUSSION: Inhaled marijuana use has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum. Spontaneous pneumomediastinum is a rare clinical entity defined as the presence of free air within the mediastinal structures in the absence of thoracic trauma, surgery, or medical procedure. It is a self-limiting condition resulting from alveolar rupture secondary to an acute increase in intrathoracic pressure subsequently leading to dissection of air along the bronchovascular sheath towards the mediastinum. The hypothesized pathophysiology of marijuana related pneumomediastinum is barotrauma occurring during breathing movements. SPM is managed conservatively with analgesia and treatment of the underlying etiology. Long term prognosis depends on the etiology of the SPM and involves lifestyle modification especially in the setting CHS. Diagnosis of a SPM can often be overlooked as its presenting symptoms remains non-specific. A comprehensive history should be obtained including a detailed history of tobacco and cannabinoid use in patients with intractable nausea and vomiting with a low threshold for chest imaging.Image 1.: Air within the mediastinal structures with no evidence of perforation.Image 2.: Water-soluble contrast esophagram with no evidence of contrast extravasation into the mediastinum.