What's Causing the Severe Stomach Pain and Vomiting in Teen Pot Smoker?
A 17-year-old girl presents to an emergency department (ED) with nausea, vomiting, and periumbilical stomach pain that has been worsening for the past 3 days. She tells clinicians she has vomited about five or six times a day and that the vomit has not been bloody or discolored. She has been taking ondansetron (Zofran) at home without relief, and prior to arriving at the ED that day, she had three episodes of non-bloody, watery diarrhea. The patient admits to smoking marijuana and a quarter pack of cigarettes daily, and also vaping nicotine. She describes her abdominal pain as constant and sharp, and radiating upward toward her sternum. She rates the pain intensity as 10/10, and says she cannot think of anything that has either aggravated or reduced the pain. She explains that she has not had any fever, chills, cough, shortness of breath, chest pain, or any other respiratory, gastrointestinal, or genitourinary symptoms. Her grandmother, her legal guardian, is sick at home and coughing, and has been told by the family physician to self-isolate due to suspected COVID-19, but the patient has not avoided contact with her, she notes. The patient's vital signs are stable, including oxygen saturation. Physical examination is notable for generalized abdominal tenderness to palpation without any guarding, rebound tenderness, or appendiceal signs, the medical team notes. Clinicians give the patient a bolus of normal saline intravenously and one dose of ketorolac (Acuvail), famotidine (Pepcid), and ondansetron. Results of lab tests show a complete blood count within the reference range, no leukocytosis, and normal hemoglobin and platelet counts. Significant findings include a potassium level of 3.4 mmol/L and chloride level of 96 mmol/L; glucose, electrolytes, and liver function tests are within the reference range, as are cardiac markers, C-reactive protein, and lipase levels. However, a nasopharyngeal swab to test for SARS-CoV-2 viral RNA using the Abbott ID NOW molecular testing kit returns positive results. A pregnancy test is negative, and urinalysis results are significant for 21-50/high-power field (HPF) white blood cell count, positive nitrates, many HPF bacteria, and more than 150 g/dL of ketones. Clinicians give the patient 1 g of ceftriaxone (Rocephin). The urine culture is positive for Escherichia coli >100 000 colonies/mL, which are pansensitive. Computed tomography (CT) scan of the abdomen and pelvis without contrast reveals pneumomediastinum and pneumopericardium. Clinicians then obtain a CT scan of the thorax without contrast. This reveals significant subcutaneous emphysema in the soft tissues of the neck, which extends above the clavicle and left axillary region, and extending along the left scapula anteriorly, medially, and posteriorly. There is evidence of extensive pneumomediastinum with gas along the great vessels, aorta, trachea, and esophagus. Axial computed tomography scan of the chest: Arrows point to the extensive pneumomediastinum and pneumopericardium. Clinicians also note the presence of pneumopericardium, but there is no evidence of pneumothorax, pleural effusion, or airspace consolidates, and the central airways are patent. Findings of a contrast enhanced barium esophagogram are unremarkable, with no evidence of extraluminal leak. After consulting with a thoracic surgeon, clinicians admit the patient to the pediatric intensive care unit for observation, but as recommended, there is no surgical intervention. The patient is started on maintenance intravenous fluid as well as acetaminophen and morphine, as needed to manage her pain. She continues to receive ceftriaxone for her urinary tract infection. Per protocol, clinicians initiate treatment with heparin to prevent deep vein thrombosis. On admission day 3, the baseline D-dimer level is 630 ng fibrinogen-equivalent units/mL. The pediatric infectious disease and pulmonology teams both agree about the patient's ongoing supportive treatment, and recommend an electrocardiogram, which shows no abnormalities. The patient's clinical condition continues to improve over the next few days. On admission day 4, clinicians obtain a follow-up chest x-ray and note that the pneumomediastinum is decreasing in size, with no evidence of associated pneumothorax. On admission day 7, the patient is discharged home in stable condition, and she has needed no respiratory support during her time in hospital. Discussion  The clinicians reporting this case of a teenager with a history of smoking found to have pneumomediastinum and pneumopericardium who tests positive for COVID-19 stress the importance of testing all patients with acute symptoms suggestive of COVID-19. The case authors note that diagnosing pediatric COVID-19 is challenging, and that having a positive contact or COVID-19 infection in the household, as in this case, increases a child's risk of developing COVID-19. "Our patient presented at the start of the pandemic when testing options were limited," and thus the specific strain of SARS-CoV-2 was not identified in this case, the team explains. While COVID-19 is generally less severe in the pediatric population, children are believed to be an important source of transmission even when they are asymptomatic or have mild symptoms, and there have also been reports of severe presentation in younger patients, the authors note. Spontaneous Pneumomediastinum  They add that the incidence of spontaneous pneumomediastinum is known to be increased in the presence of underlying lung conditions, including asthma (8-39%, according to reports), interstitial lung disease (18%), pneumonia, and bullous lung. The onset of spontaneous pneumomediastinum may be characterized by certain preceding events such as vomiting (24-36% of cases), exacerbation of asthma (15-24%), coughing (7-35%), sneezing (13%), physical activity (30%), and increased effort during labor (4-15%). While there are numerous reports of spontaneous pneumomediastinum in the adult population, often following ventilation (both noninvasive and invasive), the condition is only rarely associated with pneumopericardium, the case authors note. They cite a report of 12 adult COVID-19 patients with spontaneous pneumopericardium and pneumomediastinum associated with consolidation (50%), crazy paving (75%), and ground-glass opacities (100%). The cytokine storm generated by COVID-19 makes the alveolar markings more prone to rupture, and in the setting of noninvasive and invasive ventilation, can cause pneumomediastinum, the team writes, adding that associated myocarditis can also precipitate pneumopericardium. While this patient had no imaging findings such as ground-glass opacities of the lungs or pneumonia typically seen in COVID-19, her presentation with pneumomediastinum and pneumopericardium in the absence of pulmonary symptoms is unique, and likely represents the first to be reported in the pediatric population, the authors write. In addition, marijuana use has been associated with spontaneous pneumomediastinum, but in association with the patient's SARS-CoV-2 infection, the pneumomediastinum may have been triggered by vomiting secondary to marijuana withdrawal, and testing positive for COVID-19 was an incidental finding; still, the authors add, this interpretation does not account for the associated pneumopericardium. Conclusion  The authors conclude that the case emphasizes the importance of testing for SARS-CoV-2 infection in patients of all ages who present acutely to the hospital and that clinicians should obtain a "full social and medical history," so that symptoms and signs of causes other than COVID-19 are not missed. Kate Kneisel is a freelance medical journalist based Belleville, Ontario.