Description

A 14-year-old boy presented to the children's emergency department with cough, fever and dizziness which failed to respond to antibiotics. Examination revealed a 6 cm × 4 cm firm lymph node in the anterior right cervical chain and a chest X-ray showed a mediastinal mass. A CT scan demonstrated enlarged bilateral neck nodes, an 11 cm mediastinal mass with tracheal compression, an abdominal mass extending from the tail of the pancreas, enlarged coeliac lymph nodes, splenic and bilateral renal deposits consistent with Hodgkin's lymphoma, which was subsequently confirmed by open biopsy and histology of the cervical lymph node. Following the insertion of a Broviac line, he was started on a regimen of chemotherapy (COPADM 1). Prior to discharge some difficulty with aspirating the line was noted by the ward staff and a chest X-ray confirmed that the line was correctly placed and demonstrated an incidental finding of free air under the diaphragm (figure 1). While on conservative management, he developed abdominal pain referred to shoulder tip with abdominal distention and tenderness. At laparoscopy, pneumatosis intestinal was found in the ascending and transverse colon and an ileostomy was fashioned. He recovered with bowel function returning completely within 72 h. Chemotherapy was recommenced 11 days later. Ileostomy was closed in 8 weeks. On follow-up, he remained asymptomatic, is thriving well with normal gastrointestinal function. Pneumoperitoneum and pneumatosis cystoides intestinalis can develop after chemotherapy which are relatively rare and in most instances may have a benign self-limiting course but they may become symptomatic and require further intervention as demonstrated by our case.1–3

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Figure 1

(A) Preoperative chest radiographs showing pneumoperitoneum and (B) Postoperative one demonstrating normal appearance.