Secondary pneumothorax is a very common medical emergency. At times it is associated with pneumomediastinum, which could be fatal at times if not identified. We present a case of a 11 years old sputum positive child who presented with both these conditions and was diagnosed on chest x ray

Bhatia, V

Jhobta, A

Mokta, JK

Panda, P

Sharma, S

Sood, RG

English

RG Sood

Sanjiv Sharma

JK Mokta

Anupam Jhobta

Vikas Bhatia

P Panda

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Pneumothorax and Pneumomediastinum in a Sputum Positive Tuberculosis Patient: The Continuous Diaphragm Sign

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 Case Report:
Pneumothorax and Pneumomediastinum in a Sputum Positive Tuberculosis Patient: The 
Continuous Diaphragm Sign
RG Sood, Professor, Dept. of Radio Diagnosis and Intervention Radiology,
Sanjiv Sharma, Professor, Dept. of Radio Diagnosis and Intervention Radiology,
JK Mokta, Associate Professor, Dept. of Medicine,
Anupam Jhobta, Associate Professor, Dept. of Radio Diagnosis and Intervention Radiology,
Vikas Bhatia, Senior Resident, Dept. of Radio Diagnosis and Intervention Radiology,
P Panda, Senior Resident, Dept. of Medicine,
Indira Gandhi Medical College, Shimla.
Address for Correspondence:
Dr. Prashant Panda,
Senior Resident,
Dept. of Medicine,
Indira Gandhi Medical College,
Shimla. 
E-mail: prashantpanda85@gmail.com
Citation: Sood RG, Sharma S, Mokta JK, Jhobta A, Bhatia V, Panda P. Pneumothorax and Pneumomediastinum in a Sputum Positive  
Tuberculosis Patient: The Continous Diaphragm Sign. Online J Health Allied Scs. 2012;11(1):16
URL: http://www.ojhas.org/issue41/2012-1-16.htm
Open Access Archives: http://cogprints.org/view/subjects/OJHAS.html and http://openmed.nic.in/view/subjects/ojhas.html
Submitted: Feb 19, 2012; Accepted: Mar 24, 2012; Published: Apr 15, 2012
Abstract: Secondary pneumothorax is a very common medical 
emergency. At times it is associated with pneumomediastinum, 
which could be fatal at times if  not  identified. We present a 
case of a 11 years old sputum positive child who presented with 
both these conditions and was diagnosed on chest x ray.
Key Words: Pneumothorax; Pneumomediastinum; Continuous 
diaphragm sign.
Introduction:
Pneumothorax is commonly seen condition in emergency set-
ting. They are divided into primary and secondary pneumothor-
ax depending on whether underlying lung disease is present or 
not. Pneumomediastinum can be associated with pneumothorax 
but usually it is seen in patients of trauma or in patients with 
iatrogenic injury. We report a case of a 11 years old sputum 
positive tubercular child who presented with both these condi-
tions and was diagnosed on chest X-ray.
Case Report:
A 11 years old male with history of weight loss for 4 months 
and cough with fever for four days was brought to emergency 
department with complaints of shortness of breath. Fever was 
documented, around 99 to 100 F. Cough was productive, whit-
ish in colour and was not associated with any blood. Child had 
history of weight loss which was undocumented. Four days pri-
or to admission he started complaining of shortness of breath 
which was sudden in onset not associated with chest pain. This 
shortness  of  breath was  progressive.  On examination  patient 
was in distress with a respiratory rate of 24/min, with a blood 
pressure of 100/70 mmHg and a pulse rate of 100/min. General 
physical examination revealed mild pallor and axillary lymph 
nodes which were insignificant and there was no evidence of 
subcutaneous emphysema. Rest of the general physical examin-
ation was normal.  In  respiratory examination,  trachea was in 
the midline there were decreased chest movements in the left 
infra-axillary and infrascapular region. On percussion there was 
hyper-resonant note in the left infrascapular and left infra-axil-
lary region. On auscultation, breath sounds were decreased in 
the left infrascapular and left infra-axillary region. Cardiovas-
cular examination was normal.
Bio  chemical  and  haematological  investigations  were  within 
normal limits except for mild anaemia and and an ESR of 45 
mm. Chest radiography (Fig 1) revealed evidence of left sided 
pneumothorax (star) with right side mediastinal shift. Patches 
of consolidation were evident in bilateral lung fields. There was 
evidence of visualisation of thin lucency of gas seen between 
the heart and diaphragm making the diaphragm visible where it 
is normally obscured by the heart suggestive of continuous dia-
phragm sign (thin black arrows). The observation of continuous 
diaphragm sign in this patient helped in diagnosing the associ-
ated pneumomediastinum. 
Sputum for AFB was sent in the view of patients clinical profile 
which was 3 + AFB positive. Patient was managed with chest 
tube insertion on left side and was put on CAT 1 antitubercular 
regimen according to his weight. Patient was given supportive 
care and was observed, his pneumomediastinum and pneumo-
thorax  disappeared and  lungs  expanded  well.  His  chest  tube 
was removed on the 5Thday of admission and patient was dis-
charged on ATT.
Discussion:
Pneumothorax is defined as the presence of air in the pleural 
space. Pneumothorax is classified as spontaneous (not caused 
by trauma or  any obvious  precipitating factor),  traumatic,  or 
iatrogenic.  Primary spontaneous pneumothorax occurs in per-
sons without clinically apparent lung disease; secondary spon-
taneous  pneumothorax  is  a  complication  of  preexisting  lung 
disease. Iatrogenic pneumothorax results from a complication 
of a diagnostic or therapeutic intervention. Traumatic pneumo-
thorax is caused by penetrating or blunt trauma to the chest,  
with  air  entering the pleural space directly through  the chest 
wall;  visceral  pleural  penetration;  or  alveolar  rupture  due  to 
sudden compression of the chest.[1]
In contrast to the benign clinical course of a primary spontan-
eous pneumothorax, secondary spontaneous pneumothorax is a 
potentially  life-threatening  event,  because  patients  with  this 
condition have associated lung disease and limited cardiopul-
monary reserve. There are numerous causes of secondary pneu-
mothorax, important ones are diseases of airway, infectious dis-
ease of lung, connective tissue disorders, cancer etc.[1]
1
Online Journal of Health and Allied Sciences
Peer Reviewed, Open Access, Free Online Journal
Published Quarterly :  Mangalore, South India : ISSN 0972-5997
Volume 11, Issue 1; Jan-Mar 2012
This work is licensed under a
Creative Commons Attribution-
No Derivative Works 2.5 India License
Fig 1: Chest x ray PA view showing left sided pneumothor-
ax (star) with continuous diaphragm sign (thin black ar-
rows) suggestive of pneumomediastinum
Pneumomediastinum occurs after alveolar rupture as gas travels 
along  the  bronchovascular  interstitial  sheaths  into  the  medi-
astinum.[2]  Nontraumatic  causes include  invasive  procedures 
and  mechanical  ventilation,  airway  obstruction,  barotrauma, 
and pulmonary or  pericardial infections,  and it  has also been 
described after dental extractions.[3] There are many causes of 
pneumomediastinum  and  several  radiographic  signs:  pneu-
mopericardium,  continuous  diaphragm  sign,  continuous  left 
hemidiaphragm sign, Naclerio’s V sign, V sign at confluence of 
brachiocephalic veins, ring-around-the-artery sign, thymic spin-
naker-sail  sign,  and extrapleural air  sign.[4] Identifying these 
signs are important because this condition presents with subtle 
signs and can be life threatening in few cases. The identifica-
tions of these signs on x ray can avoid the use of costly invest -
igations like CT chest in our resource scarce country.
Management of pneumothorax is with chest tube insertion and 
usually pneumomediastinum is observed and managed conser-
vatively. The issue of prophylactic antibiotic coverage in pneu-
momediastinum is contradictory. All patients in one study re-
ceived at  least  one  dose  of  a  third-generation  cephalosporin. 
That seemed reasonable, particularly in highly suspicious cases 
and until any additional workup is completed. Although recent 
reports  from smaller  series advocate immediate admission  or 
expedite diagnostic approach, it was found that pneumomedi-
astinum does not usually require aggressive intervention or hos-
pitalization. Taking into consideration the benign nature of this 
entity, only cases, where the diagnosis is in question, the under-
lying disease needs specific treatment or the possibility of an 
organ perforation cannot be ruled out, should be considered for 
further diagnostic workup and admission.[5] As seen in our pa-
tient, pneumomediastinum usually improves with conservative 
management.
References:
1. Sahn  SA,  Heffner  JE.  Spontaneous  Pneumothorax.  N 
Engl J Med 2000;342:868-874
2. Brander  L,  Ramsay  D,  Dreier  D et  al.  Continuous  left 
hemidiaphragm  sign  revisited:  a  case  of  spontaneous 
pneumopericardium  and  literature  review.  Heart. 
2002;88:e5.
3. Zylak CM, Standen JR, Barnes GR, et al. Pneumomedi-
astinum revisited. Radiographics. 2000;20:1043–1057
4. Bejvan SM, Godwin JD. Pneumomediastinum: Old Signs 
and New Signs. AJR 1996;166:1041-1048.
5. Koulliasa GJ, Korkolisa DP, Wangb XJ, Hammond GL. 
Current  assessment  and  management  of  spontaneous 
pneumomediastinum:  experience  in  24  adult  patients. 
European  Journal  of  Cardio-thoracic  Surgery 
2004;25:852–855.
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Pneumothorax and Pneumomediastinum in a Sputum Positive Tuberculosis Patient: The Continuous Diaphragm Sign

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