An 82-year-old male patient was referred to our accident and Emergency (A & E) Department from a primary level hospital after sustaining a blunt injury of the thorax. The mechanism of the injury was a fall from few stairs without loss of consciousness. On arrival, he had signs of mild respiratory distress (SpO2
: 92% on room air, RR: 24/min), and he was hemodynamically stable (BP: 157/96
mmHg, HR: 99/min) and alert (Glasgow Coma Scale: 15). During the initial assessment, a subcutaneous emphysema extending from the eyelids to the anterior abdominal wall was palpable. Moreover, the patient had an open wound on his forehead, on the helix of his left ear extending to the ipsilateral external auditory canal, and on his left calf and abrasions at his right forearm. The rest of the physical examination was normal. His past medical history included diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure, hypertension, dyslipidemia, and hypertension.
Central vein access was gained, and blood tests (complete blood count, complete blood chemistry, blood type, Rhesus determination, and serologic markers for hepatitis) were obtained. By that time, there was no evidence of air inside the scrotum, and a foley catheter was inserted without difficulty.
Laboratory data revealed elevation of white blood cell count (16.4
L with 91.9% neutrophils), abnormal blood urea nitrogen (68
mg/dL), creatinine level of 2.0
mg/dL, and 20–25 urine RBC per high power field. Other laboratory measurements were unremarkable.
The patient was transferred to the Radiology Department for basic X-ray studies, ultrasonography exams, and CT scanning (head, cervical spine, thorax, abdomen, and pelvis). The body CT scan revealed a massive subcutaneous emphysema extending from the temporal-parietal region of the head to the scrotum (Figures and ), one broken rib (7th) at the right, and three broken ribs (2nd, 3rd, and 6th) at the left hemithorax, bilateral pneumothorax with pneumomediastinum, and right lower lobe infiltrates (). No pneumoretroperitoneum was evident. The rest of the investigations were negative.
Figure 1 (a) Computed tomography scan of the pelvis. Air (white arrows) is visualized within the scrotal sac (indicative of pneumoscrotum). (b) Magnification of the red frame of (a). Air appears to the scrotum (white arrows) and at the base of the penis (head (more ...)
Computed tomography scan of the thorax. Bilateral pneumothorax (black arrows), pneumomediastinum (arrow heads) and subcutaneous emphysema of the anterior and lateral thoracic wall (white arrows).
During second assessment of the patient, the scrotum had enlarged, and a crepitus was palpable with no septation. A puncture in the scrotum confirmed the diagnosis of pneumoscrotum (). A chest tube was inserted to right hemithorax. The left pneumothorax was small (<15% as estimated by the Light's index) and managed conservatively. The rest of the treatment was supportive. Pneumothorax was absorbed after few days of hospitalization. At day 13, he was transferred to the Respiratory Department due to low fever, bilateral pleural effusions, and lung infiltrations, diagnosed by a new chest CT scan (). He was treated successfully with parenteral antibiotics for eight days. The rest of his course was uneventful. By the time of discharge, subcutaneous emphysema of the scrotum was completely absorbed.
Computed tomography of the thorax at day 13 demonstrates right pneumothorax (white arrow) with lung infiltrations and bilateral pleural effusions (black arrows). The chest tube is visible (head arrows).