Correspondence

Medical Mystery — The Answer

N Engl J Med 2000; 342:740March 9, 2000

Article

To the Editor:

The medical mystery in the January 20 issue1 involved a 79-year-old woman who presented to the emergency department with a several-hour history of facial swelling (Figure 1AFigure 1A 79-Year-Old Woman with Facial Swelling.). She had chronic obstructive pulmonary disease. The swelling of her head and neck had developed and progressed in a few hours, despite antihistamine and glucocorticoid treatment. She had fallen on her left side two days before admission. Physical examination revealed massive symmetric subcutaneous emphysema that involved the whole upper part of the body and the arms, extending to the fingernails. A chest film (Figure 1B) and a computed tomographic (CT) scan (Figure 1C) confirmed the presence of extensive subcutaneous and mediastinal emphysema, with a rib fracture (arrows). A traumatic anterior pneumothorax was present on the left side, which could be seen only on the CT scan. The loss of elasticity with increased closing volume in the patient's lungs probably prevented a total pneumothorax. The emphysema resolved in a few days after the placement of a chest tube. The photograph shown in Panel D of Figure 1 was taken seven days after the photograph shown in Panel A.