Spontaneous subcutaneous emphysema: An uncommon presentation of a common disease

A 16-year-old female, non-smoker, presented to the Emergency Department (ED) with sudden onset swelling over the face, neck, chest, and upper abdomen for 2 days. She had history of intermittent low-grade fever and dry cough for 1 month prior to the presentation. There was no history of exposure to any organic or inorganic particulate. Primary survey was normal, except low oxygen saturation (SpO2) of 93% which improved to 99% with 6 L/min of oxygen by face mask. On examination, there was swelling over the face, neck and torso with crepitus palpated all over the swollen area. On auscultation, crepitation was heard over the chest. Chest radiograph showed gross subcutaneous emphysema (SE) with ‘Ginkgo leaf sign’ with hyper-inflated lung fields (Fig. 1). Computed tomography (CT) of thorax showed gross subcutaneous emphysema, with segmented pneumothorax and active cavitary lesion in left upper lobe posterior segment, probably of infective etiology (Fig. 2). No rent was seen in the trachea and main bronchi. She was admitted and further evaluation was completed with positive sputum acid-fast bacilli (AFB). Anti-neutrophil cytoplasmic antibodies were negative. Anti-tuberculosis treatment was started and SE gradually resolved over 15 days.