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Description
A 20-year-old nursery teacher presented with swelling of the left hand, arm and shoulder. She had a history of self-harm, deliberate recurrent right patella dislocations and gabapentin overdose. Recently she had undergone right knee diagnostic arthroscopy. Clinical examination revealed surgical emphysema, and this was confirmed radiologically. There was no pneumothorax on the chest radiograph (fig 1). Over the following 48 h the emphysema extended to involve the entire chest wall, neck and face and a few needlestick marks were noted on the hands and arms. The radiograph now confirmed that she had a pneumomediastinum. CT of the chest, bronchoscopy and gastrografin swallow failed to identify the cause (figs 2 and 3). It was observed that she would leave the ward for hours at a time at night, and when this was prevented, the emphysema did not progress. Subsequently the patient admitted to puncturing the skin with a Vacutainer needle and blowing air under the skin through the other end, having removed the rubber sheath. She had noted that a needle could be placed into the subcutaneous space while observing failure of correct placement of a line for intravenous access for her knee surgery. She stated that she had done this as an escape from the trauma of abuse as a child. While on the ward she was assessed by psychiatric liaison team and given a follow-up appointment in the community.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.