Q & A: Spontaneous Pneumothorax

Q: One of my patients had a past medical history of a collapsed lung, which her physician called spontaneous pneumothorax. Is this a recognized complication of anorexia nervosa? (AL, Tallahassee, FL)

A: Spontaneous pneumothorax occurs when a subpleural pulmonary bleb (basically a structural bubble) bursts, and air rushes into the pleural space between the lung and chest wall. The lung then collapses in response to this sudden buildup in air pressure where no air previously existed. Spontaneous pneumothorax most often occurs in young adult individuals with a lean body build, most typically males. These young men usually present with acute chest pain and progressive shortness of breath. In instances where small amounts of air have leaked into the chest wall cavity, treatment can be conservative, and the air may be reabsorbed spontaneously. However, in more serious cases, chest tubes are inserted to help the air escape and the lung to re-inflate.

One case has been reported in a patient with anorexia nervosa, and the authors assume that others have occurred as well (Adson et al, Psychosomatics 1998, 39:162). However, a larger number of patients with anorexia nervosa have developed “spontaneous pneumomediastinum” In this situation, high intrathoracic pressure, sometimes associated with vomiting, leads to high intra-alveolar pressure, rupture of perivascular alveoli and escape of air into connective tissues and dissection of air into the mediastinum. Symptoms include acute pleuritic chest pain, shortness of breath and neck pain, and several specific signs on physical examination of the chest.

The important point here is that patients who are vomiters who develop this syndrome require an immediate contrast x-ray of the esophagus to rule out perforation (Booerhaave’s syndrome). If untreated, this condition may lead to peritonitis and result in death, and thus must be surgically corrected as quickly as possible.

— J.Y.