In Their case report in JAEM Pitman and Pounsford reported
pneumomediastinum occurring in a girl who had been at a rave and danced
blowing a whistle almost continuously for 8 hours.
The pathophysiology of pneumomediastiunum in general is well described as
occuriing with raised intra-alveolar pressure or reduced interstitial
pressure resulting in the rupture of the alveolar sac and extravasation of
the air into perivascular fascia. The air then tracks back along the
vessels into the mediastinum.
It has been postulated that the mechanism for pneumomediastiunum in other
'recreational' drugs is forceful breath holding following inhalation
creating a Valsalva type manoeuvre and increase of the intra-alveolar
pressure and rupture of the alveoli.
Quin McCarthy and Harries described another case in JAEM where there had
been ingestion of ecstasy but no episode of repeated valsalva maneouvre,
though the patient had been dancing for several hours.
In Rezvani and Brenton's 2 cases, one had occurred after retching, the
other is described as developing signs having been at a party but there was
no mention of any 'valsavaesque' maneouvre. They concluded that it was
most likely due to the severe physical exercise associated with its use as
an 'energy enhancing' drug.
Levine in J R Soc Med described pneumomedastinum following ecstasy in
association with an episode of vomiting.
Our case was a 16 year old who presented having taken 6 ecstasy tablets
over 2 hours. He had a period of retching before noticing swelling in his
neck.
It is interesting looking at the various case reports how different people
get investigated. Everyone got admitted, some just had x-rays, some had CT
scans, some had gastrograffin swallows, some had surgical reviews and
Cardiothoracic reviews. In our case the surgeons though it was likely
oesophageal while the physicians though it was pulmonary in origin. All
patients had uneventful outcomes as is the usual case with 'spontaneous'
pneumomediastinum.
Thus the evidence would suggest ? that the cause is not pharmacological
per se or dose related but due to the valsalva manoeuvres associated with
the 'culture' of ecstasy taking or the retching induced by the drug.
Regards
John Ryan
PS Our chap got such a fright that he is now going to 'give up substance
misuse and take up skate boarding instead' !
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