Description
An otherwise healthy 72-year-old woman presented with dyspnoea and systemic subcutaneous emphysema. She had undergone upper endoscopy, in which duodenal ulcer was found. The community hospital where the endoscopy was conducted transferred her to our tertiary hospital for further diagnosis and management. On arrival, she complained of severe difficulty in breathing; massive subcutaneous emphysema on her chest to the feet was observed on palpation. Chest X-ray image showed Naclerio's V sign (figure 1A, black arrow) and continuous diaphragm sign (figure 1A, white arrows). CT scan confirmed massive subcutaneous and mediastinal emphysema with pneumothorax, pneumopericardium and free air in retroperitoneal space (figure 1B,C). Emergent laparotomy revealed duodenal perforation, 9 mm in diameter at the descending part of duodenum (figure 1D, white arrow), and was surgically repaired. After the surgery, the emphysema gradually disappeared in weeks and had not recurred at 6-month follow-up.
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