Pneumomediastinum and pneumorrhachis from recreational nitrous oxide inhalation: no laughing matter

Spontaneous pneumorrhachis with pneumomediastinum, scrotal emphysema, and extensive subcutaneous emphysema in a patient with pneumonia: A case report and literature review

BACKGROUND

Spontaneous pneumorrhachis with pneumomediastinum, scrotal emphysema, and extensive subcutaneous emphysema caused by acute pneumonia are rarely observed in clinical practice.

CASE PRESENTATION

Herein, we report a case of a 12-year-old boy with spontaneous pneumorrhachis with pneumomediastinum, scrotal emphysema, and extensive subcutaneous emphysema caused by a severe cough due to mycoplasma pneumonia. This patient neither received invasive or noninvasive ventilator treatment nor surgical treatment before the onset of the disease. After treatment, the patient recovered smoothly and was discharged from the hospital.

LITERATURE REVIEW

We reviewed all cases of spontaneous pneumorrhachis in children and adolescents between 1988 and 2022 in the PubMed database. Twenty-seven cases met our inclusion criteria, and the data on demographic information, triggers, comorbidities, symptoms, imaging findings, treatment, and prognosis were extracted and analyzed.

CONCLUSION

Although spontaneous pneumorrhachis is a rare condition, it has been reported in children. Computed tomography scanning is the gold standard for its detection. Spontaneous pneumorrhachis is typically a benign disease. This condition usually does not require any special treatment and should be monitored as common types of air leaks, such as pneumothorax and pneumomediastinum.

Addictovigilance in women, the hidden part of the iceberg?

Epidemiology of substance use disorders and their complications is driven by a male predominance, and women, even if they are more and more prevalent, are never specifically represented in studies in the field. Apart from the time of pregnancy, which in itself requires specific prevention, treatment and follow-up, the importance of the sex of women in the complications of substance abuse is neglected. To illustrate, we described some characteristics of women identified in the addictovigilance information system in France and Europe, related to drug use disorders (both for illicit substances and medications). Even if the exposure to some psychoactive substances remains more prevalent in men, women, and particularly young women, seem to be more vulnerable to the adverse effects of these substances, as observed for opioid analgesics, benzodiazepines, cannabis and even nitrous oxide. It is now imperative that the female sex/gender be taken into consideration in addictovigilance expertise and in drug safety in general, even for substances for which use is predominantly male. In addition, the adequate management of the women requires the development of specific prevention and care strategies.

[Acute and chronic toxicities associated with the use and misuse of nitrous oxide: An update]

Nitrous oxide (N₂O) is used since the eighteenth century as an anesthetic and analgesic but also for recreational use. If the labelled uses of N₂O and their modalities are nowadays perfectly framed, the misuse of N₂O takes very alarming proportions among teenagers and young adults. This misuse is the cause of acute (hypoxia, barotrauma, burns, neuropsychiatric disorders) and chronic complications if repeated (myeloneuropathy, anemia, thrombosis, inhalant use disorder). The main mechanism of the latter is mainly related to a functional deficit in vitamin B12 induced by N₂O. The management of acute complications is symptomatic. The management of chronic complications is based on vitamin B12 supplementation. The best biomarker of chronic N₂O exposure is the elevation of the plasmatic level of methylmalonic acid. In all cases of recreational misuses, addiction treatment is necessary to prevent complications or their worsening by providing information in order to stop consumption.

The dangers of recreational inhalation of nitrous oxide

Nitrous oxide, also known as 'laughing gas', is one of the most widely used recreational drugs among teenagers in the UK. Copious inhalation of nitrous oxide may increase intra-alveolar pressure, resulting in barotrauma secondary to alveolar rupture. Pneumomediastinum and subcutaneous emphysema are common clinical findings in nitrous oxide-associated barotrauma. Prolonged nitrous oxide misuse may inactivate vitamin B₁₂ through the alteration of its metabolism, causing demyelination of the central and peripheral nervous system. A spectrum of neurological manifestations has been reported, including peripheral neuropathy, myelopathy and subacute combined degeneration of the spinal cord. Medical therapies and psychosocial interventions aiming at nitrous oxide cessation are important treatment steps to achieve partial or complete recovery from the adverse effects associated with inhalation of nitrous oxide.

Case report: Tension pneumomediastinum from opioid inhalation

Pneumomediastinum is a rare complication of substance use, likely due to a Valsalva maneuver after drug inhalation. There are no previously documented associations between pneumomediastinum and opioid use. A 30-year-old man with a history of recent heroin and fentanyl inhalation presented to the emergency department in respiratory distress requiring intubation. His course was complicated by pneumomediastinum which subsequently developed tension physiology. He required emergent surgical decompression with a “blowhole incision” to his anterior chest. Although a rare complication of polysubstance use, pneumomediastinum can progress to tension physiology, requiring prompt diagnosis and management.

A model of lipid dysregulation and altered nutrient status in Alzheimer's disease

INTRODUCTION

Dysregulated lipid metabolism and nutrient status are thought to play a role in the pathophysiology of Alzheimer's disease (AD). However, the precise involvement is not well understood, and it remains unclear exactly how such dysregulated lipid metabolism and altered nutrient status, especially changes in phosphatidylcholine, B12, and folate, are connected to the hallmark pathology in AD (i.e., amyloidogenesis).

METHODS

We have postulated that genetic susceptibility (i.e., APOE ε4/ε4) to environmental exposure to emissions of nitrous oxide (N2O) could underlie the onset of AD and its early neuropsychiatric correlates.

RESULTS AND DISCUSSION

The current theoretical editorial describes, using clinical, preclinical, and in vitro evidences, how this model contributes not only to amyloidogenesis but also other nonopioid effects, specifically altered lipid metabolism, depletion of vitamin B12, and disruption of the folate-mediated one carbon metabolic pathway.