Download Spontaneous pneumomediastinum

Manuscript No:
20120104 OJS 70
(Dr Abdulla Al-Abassi)
I have read the manuscript
Pneumomediastinum in early pregnancy associated with Boerhaave syndrome
And recommended that it should be:
accepted without change
accepted with minor changes
reassessed after major revision
reject
accept as brief communication
If the recommendation is to accept, please recommend a priority:
High
Average
Low
If priority is HIGH please give rank (1-10)
CONFIDENTIAL Comments to the Editor:
Dear Dr. Saud,
Thank you for giving me the opportunity to participate in the evaluation of this
article on behalf of the Saudi Medical Journal.
A major revision has to be undertaken before accepting the manuscript to be
published in the SMJ. Comments and suggestions are given in “Remarks to Authors”
Please check the manuscript number: 2012104 or 2012107 ? However, the title
is correct.
Yours sincerely,
Dr Abdulla Al-Abassi, FRCS-Ed; FACS.
Advisory Board Member, SMJ.
Consultant General Surgeon,
Saqr Hospital, Ras Al Khaimah,
United Arab Emirates.
E-mail: [email protected]
[email protected]
*Please let us know if you can review the revised manuscript:
Yes, I will review the revised manuscript
No. I will not review the revised manuscript
Manuscript No:
20120104 OJS 70
Remarks to Author(s)
1. There is mixing between spontaneous esophageal rupture (Boerhaave Syndrome) and
spontaneous pneumomediastinum (SPM) which usually runs a benign course and is
due to many etiological causes, including pregnancy which is not mentioned at all in
the manuscript. See the following references:
a. Ir J Med Sci. 2008 Dec;177(4):393-6. Epub 2007 Jul 6.
Spontaneous pneumomediastinum: a rare complication of acute asthma.
Khalid MS, Ahmad N, Moin S, El-Faedy O, Gaffney P.
b. Neth J Med. 2007 Nov;65(10):368-71.
Mediastinal emphysema complicating diabetic ketoacidosis: plea for
conservative diagnostic approach.
Pauw RG, van der Werf TS, van Dullemen HM, Dullaart RP.
c. Ann Thorac Surg. 2004 Aug;78(2):711-3.
Spontaneous pneumomediastinum.
Langwieler TE, Steffani KD, Bogoevski DP, Mann O, Izbicki JR.
d. Chest. 1994 Dec;106(6):1904-6.
Pneumomediastinum and bilateral pneumothoraces in a patient with
hyperemesis gravidarum.
Schwartz M, Rossoff L.
e. Obstetric Medicine: December 2010 3:158-160.
Spontaneous pneumomediastinum: a rare presentation of diabetic
ketoacidosis in a pregnant woman.
Leonie Speksnijder, Johannes J Duvekot, Erik J J Duschek, Max C W Jebbink,
Henk A Bremer.
2. The history, clinical presentation and esophageal contrast study of the patient are
suggestive of SPM rather than Boerhaave syndrome. The authors made no effort to
consider other possible causes of pneumomediastinum and surgical emphysema.
3. The “Introduction” was deceptive in implying that the presence of The presence of
"Mackler's triad is suggestive of Boerhaave syndrome. The presence of "Mackler's
triad" of vomiting, chest pain, and subcutaneous emphysema in conjunction with
hematemesis and a brisk leukocytosis would suggested the possibility in this case.
[Chest. 1994 Dec;106(6):1904-6. Pneumomediastinum and bilateral pneumothoraces
in a patient with hyperemesis gravidarum. Schwartz M, Rossoff L.].
1. Chest X-Ray images, which are usually informative in SPM, are not provided in the
manuscript.
2. Period of follow up and if further radiological investigations are performed are not
mentioned.
3. The concluding statement on pneumomediasinum at the end of discussion is not
supports by the medical literature and does not reflect the essence of the case which
stresses on the importance of conservative management.
4. Few references are provided. Two of the five mentioned references are old (1927 &
1945).
5. The language is relatively poor and needs to be corrected. Some suggestions to
language correction and manuscript modification is given below:
TITLE: Pneumomediastinum in early pregnancy: A case report
Abstract:
Maternal pneumomediastinum associated with subcutaneous emphysema is a rare
complication of pregnancy, occurs most frequently in the second stage of labor. It can be a
sign of spontaneous esophageal breaching due to excessive vomiting in early pregnancy. We
report a case of pneumomediastinum and subcutaneous emphysema associated with
hyperemesis gravidarum in early pregnancy treated conservatively with successful outcome.
Introduction: [THE INTRODUCTION HAS TO BE MODYFIED TO REFLECT THE
CHANGES IN TITLE AND ABSTRACT AND SHOULD BE SUPPORTED BY
APPROPRIATE REFERENCES].
Case report:
A 19-year-old primigravida was admitted at 13 weeks' gestation for brutal appearance of
retrosternal continuous pain with cervical radiation and crackling sensation in the neck. Her
early pregnancy was marked by nausea and persistant vomiting (many times per day) with
anorexia responsible of 11 kg weight loss.
On physical examination she was anxious and slightly in pain but did not look ill. Vital signs
were normal, no fever and no hemodynamic instability. Right and left supraclavicular
subcutaneous emphysema was palpable. She had good bilateral air entry. Laboratory tests
showed hypokalemia. Leukocytic count was normal.
A chest X-ray and thorax computed tomography (CT) revealed obvious pneumomediastinum
around the trachea, the pericardium, and extensive subcutaneous emphysema in the neck and
upper chest. There was no pneumothorax, pleural effusion or other pulmonary abnormalities
(fig. 1,2).
In view of her good general condition, the patient was treated conservatively with intravenous
fluids and nasogastric suction of stomach secretions. Systemic antibiotic therapy
(piperacillin/tazobactam) and proton pump inhibitors (omeprazole) were initiated. Total
parenteral nutrition of 2500 kcal/day was started on the second hospital day. Vomiting was
controlled by intravenous antiemetic medications (ondansetron).
An esophageal barium dye study (ON WHICH DAY?) did not reveal extravasation into the
periesophageal space. (WHY BARIUM AND NOT WATER SOLUBLE CONTRAST WAS
USED).
After 12 days of hospitalization, the patient was allowed for sips of water which was well
tolerated. Clear fluids started on the following day.
Regular obstetric examination and fetal ultrasonography were normal.
The patient gained 2 kg during hospitalization to reach 71 kg and left the hospital on day 15
with ameliorated diet (?!).
She was followed in outpatient clinic with good recovery and without recurrence of
symptoms. [PERIOD OF FOLLOW UP?]
Discussion: [THE DISCSSION HAS TO BE MODYFIED TO REFLECT THE CHANGES
IN TITLE AND ABSTRACT AND SHOULD BE SUPPORTED BY APPROPRIATE
REFERENCES].