A 15-year-old adolescent male presented to the ED with respiratory distress and low oxygen saturation. He was tachypneic (respiratory rate 24/min), lethargic, and hypoxic (oxygen saturation 86% on room air), requiring face mask oxygen to maintain saturations during ambulance transfer. He had a dry cough for one week and a fever for four days. On the morning of the presentation, he experienced several episodes of vomiting, after which he developed sharp, stabbing central chest and back pain. His mother also reported swelling of the left side of his neck and face that began that same morning.

He had a previous history of bronchiolitis in infancy, which had resolved without residual lung disease on follow-up. He also had mild asthma, controlled with occasional use of a salbutamol inhaler. He had not undergone any intervening chest imaging before this presentation. There was no family history of spontaneous pneumothorax or connective tissue disorders. He admitted to vaping and inhaling cannabis, reporting that he had been vaping for the past year and consumed approximately 3,500 puffs per week.

On arrival to the ED, his heart rate was 100 beats per minute, blood pressure 122/76 mmHg, capillary refill time <2 seconds, and temperature 37 °C. He appeared mottled, and examination revealed palpable crepitus on the left side of the neck, chest, and abdomen. He had good bilateral air entry with normal breath sounds. He received 15 liters of oxygen via a non-rebreathing mask to maintain saturations at 100%, a fluid bolus of 10 ml/kg, and a stat dose of cefotaxime.

His chest X-ray on admission demonstrated diffuse subcutaneous emphysema, most prominent around the neck and upper chest wall, with associated pneumomediastinum (Figure 1).

Furthermore, a contrast-enhanced CT scan of the chest revealed extensive subcutaneous emphysema, pneumomediastinum, pneumothorax, and pneumorrhachis, with no evidence of esophageal perforation or extraluminal contrast leakage (Figure 2). The CT report also noted consolidation in the left lower lobe and subpleural ground-glass opacities in the right upper lobe, although some findings were not clearly visible on the provided representative images.

Subsequently, he was admitted to the Pediatric High Dependency Unit for monitoring. He did not tolerate high-flow nasal cannula oxygen, so he was continued on 60% oxygen via face mask to maintain oxygen saturations above 95%. He was managed with total parenteral nutrition, empirical antibiotics (IV co-amoxiclav and oral clarithromycin, to which the organisms were later confirmed sensitive), omeprazole, and analgesia, and was kept nil by mouth for a total of seven days due to potential concerns of esophageal perforation.

His blood results showed hemoglobin 162 g/L, white cell count 7.1 × 10⁹/L, platelets 149 × 10⁹/L, and CRP 148 mg/L. Urine toxicology was positive for cannabinoids. It was not documented whether he continued vaping or inhaling cannabis during the symptomatic period before admission; given that cannabinoid metabolites can remain detectable in urine for several days to weeks in regular users, the positive result could not distinguish between ongoing and prior use. Respiratory PCR was positive for adenovirus, and sputum culture grew Haemophilus influenzae and Group A streptococcus.

A repeat barium swallow after 10 days did not show any evidence of esophageal leak. He was restarted on oral feeds, and total parenteral nutrition was discontinued on day 8 of admission. He required 2.5 days of oxygen therapy during his admission and received a total of 1 week of antibiotics before being discharged with a three-week course of oral omeprazole and outpatient pediatric follow-up.

The patient’s vital signs and laboratory investigations are summarized in Table 1.