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Letters to the Editor
Subcutaneous emphysema mimicking angioedema Sir, Subcutaneous emphysema is an uncommon entity that may be associated with an underlying pneumothorax. Timely intervention in the form of early diagnosis and treatment is important to avoid a fatal outcome.[1,2] It may mimic angioedema, a common and often a relatively benign disorder thereby leading to inappropriate management. [3] We report a case of a 65‑year‑old man who was referred to the dermatology outpatient department for evaluation of progressively increasing facial swelling of two days duration associated with difficulty in breathing. There was no preceding history of drug intake. There was no history of any food allergy, drug allergy, or similar such episodes in the past. He was a chronic smoker and a known case of chronic obstructive pulmonary disease (COPD). He developed acute respiratory distress three days ago and was subsequently diagnosed as a case of angioedema by a dermatologist and was prescribed tablet prednisolone 40 mg daily and tablet hydroxyzine 25 mg thrice daily with no symptomatic improvement over the next two days. Physical examination revealed the presence of a diffuse facial swelling predominantly involving periorbital region and both cheeks extending down to the supraclavicular region and upper chest. However, there was distinct sparing of the lips, which prompted us to look for other clues and to consider other differentials. Crepitus could be elicited on palpation of the swollen areas., Chest radiograph (posteroanterior view), showed presence of opaque striations/ shadows in the scapular region suggesting subcutaneous emphysema without any evidence of pneumothorax [Figure 1]. Therefore, a final diagnosis of subcutaneous emphysema, resulting probably from the rupture of an apical lung bulla in a patient with pre‑existing COPD was made. The patient was referred to medical emergency where he was treated with anxiolytics, bronchodilators, and administered ventilation with 100% oxygen leading to remarkable improvement in respiratory distress and satisfactory reduction in facial swelling over next three days. Subcutaneous emphysema results from entrapment of air into the subcutaneous tissues.[1,2] It can result from various causes including blunt or penetrating trauma to the chest or neck, following gastrointestinal perforation (corrosives burns of the esophagus, Boerhaave’s syndrome, gas gangrene), diving injuries, endoscopy, tracheostomy, cryosurgery, dental surgery, or skin biopsy.[1‑7] While reviewing the literature we came across only four reports of subcutaneous emphysema © 2016 Indian Dermatology Online Journal | Published by Wolters Kluwer - Medknow
mimicking angioedema[3‑5,7] where subcutaneous emphysema resulted from dental surgery in majority.[3,4] Subcutaneous emphysema may occur spontaneously as a result of increased pressure in the lungs due to rupture of alveoli, as might have happened in our patient. Subsequent to an injury or otherwise, air from the mediastinum and retroperitoneal spaces travels along the fascial planes to reach the subcutaneous region where it gets trapped, resulting in subcutaneous emphysema. Spontaneous subcutaneous emphysema may have varied clinical presentations depending on the cause, but is often associated with sudden onset dramatic swelling of the neck associated with chest pain, wheezing, dyspnea, and dysphagia. [2,7] Similarity of most of these symptoms to angioedema can lead to a misdiagnoses by the dermatologists. History of COPD along with characteristic sparing of lips and presence of crepitus on palpation prompted us to diagnose subcutaneous emphysema in our patient. Imaging techniques such as radiographs of the chest and neck regions have been used to visualize air in the subcutaneous spaces. Radiolucent striations in the subcutaneous tissues are seen in radiographs, whereas computed topography shows air as dark pockets along with the entry point of the air. [2,7] Subcutaneous emphysema usually has a benign course. Mild‑to‑moderate cases of subcutaneous emphysema may be dealt with by treatment of the predisposing factors, bed rest, anxiolytics, supplemental oxygen, and reassurance. Severe cases might require chest tube or insertion of catheter and positive pressure ventilation.[1,2] This report highlights the fact that subcutaneous emphysema is an uncommon but an important cause of facial swelling with respiratory distress that is likely to be misdiagnosed as angioedema, a commonly encountered dermatological condition.
Figure 1: Chest radiograph posteroanterior view showing radiolucent shadows in scapular and subcutaneous region of upper chest
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Letters to the Editor
Financial support and sponsorship Nil.
4.
Conflicts of interest
5.
There are no conflicts of interest.
Amit Kumar Dhawan, Archana Singal, Kavita Bisherwal, Deepika Pandhi Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital (UCMS and GTB) Hospital, Delhi, India Address for correspondence: Dr. Amit Kumar Dhawan, House No. 436, 2nd Floor Indra Vihar, Delhi ‑ 110 009, India. E‑mail:
[email protected]
REFERENCES 1.
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Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447‑53. Pan PH. Perioperative subcutaneous emphysema: Review of differential diagnosis, complications, management, and anesthetic implications. J Clin Anesth 1989;1:457‑9. Frühauf J, Weinke R, Pilger U, Kerl H, Müllegger RR. Soft tissue cervicofacial emphysema after dental treatment: Report of 2 cases with emphasis on the differential diagnosis of angioedema. Arch Dermatol
Loose anagen hair syndrome: Is there any association with atopic dermatitis? Sir, It was interesting to read the article by Avhad G, Ghuge P, Jerajani H.[1] They have reported eyebrow involvement, which is not very common in loose anagen hair syndrome (LAHS). We appreciate the authors for differentiating LAHS from other causes of hair loss in children. Earlier, LAHS was believed to be a condition affecting primarily blond hair children, but after the first report of LAHS from Egypt in the year 2009,[2] more and more cases are being reported in children with dark hair, but most of them in the form of isolated case reports. The first study on LAHS from India was published in international literature in 2013, which concluded that LAHS is probably as common in dark‑haired children as in blondes, but only underdiagnosed. In this study, male:female ratio was found equal, which suggested underdiagnosis in boys.[3] Here we would like to share our experience and views and highlight certain points.
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2005;141:1437‑40. Haitz KA, Patel AJ, Baughman RD. Periorbital subcutaneous emphysema mistaken for unilateral angioedema during dental crown preparation. JAMA Dermatol 2014;150:907‑9. Jensen P, Johansen UB, Thyssen JP. Cryotherapy caused widespread subcutaneous emphysema mimicking angiooedema. Acta Derm Venereol 2014;94:241. Yadav P, Pandhi D, Singal A. Benign subcutaneous emphysema following punch skin biopsy. J Cutan Aesthet Surg 2013;6:171‑2. Cakmak SK, Gönül M, Gül U, Kiliç A, Demirel O. Subcutaneous emphysema mimicking angioedema. J Dermatol 2006;33:902‑3.
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Cite this article as: Dhawan AK, Singal A, Bisherwal K, Pandhi D. Subcutaneous emphysema mimicking angioedema. Indian Dermatol Online J 2016;7:55-6.
Although LAHS is occasionally seen in adults, it is always important to examine parents of children diagnosed as having LAHS because most of the adult cases are diagnosed retrospectively, while examining parents of children diagnosed as having LAHS. Adult LAHS (type C), is characterized by normal‑appearing hair with excessive shedding of LAHS. There is predisposition for patients with LAHS types A and B, which are common in children, to evolve into LAHS type C with age.[4] Therefore, adult cases remain underdiagnosed and misdiagnosed as telogen hair loss. As we found familial occurrence as high as 50%, [1] parents and siblings of diagnosed cases of LAHS should always be screened. Although in most of the cases LAHS occurs in isolation, association with coloboma, Noonan syndrome, ectodermal dysplasia, ectrodactyly–ectodermal dysplasia‑clefting syndrome, trichorhinophalangeal syndrome, nail–patella syndrome, neurofibromatosis, trichotillomania, woolly hair, AIDS, and alopecia areata is reported. In our previous study, we found one patient with associated atopic dermatitis. One similar case was also found few months back [Figures 1 and 2]. Both the patients we found were in Indian Dermatology Online Journal ‑ January‑February 2016 ‑ Volume 7 ‑ Issue 1
