The patient was in no apparent distress. Examination revealed the following: oropharynx, moist mucosa and no lesions; chest, bilateral loud high pitched wheezing diffusely, with prolonged expiratory phase; cardiac, S1 S2, diminished, no murmur, regular rate and rhythm, and tachycardia; abdomen, soft, nontender, normal bowel sounds, and no hepatospleno-megaly; and extremities, no clubbing, cyanosis, or edema. The neurologic examination was unremarkable.

Laboratory Findings

Laboratory findings are as follows: WBC count, 9.8 X 103/^L with 94% polymorphonuclear neutrophils and 2% band neutrophils; hematocrit, 45%; and platelet count, 276 X 103/^L. Calcium measurement, liver function test results, and electrolyte levels were normal. No infiltrates were evident on chest radiograph, and ECG revealed no acute changes.

Clinical Course

The patient was admitted to the hospital with a diagnosis of asthma exacerbation. She improved with IV steroids, bronchodilators, and antibiotics Pharmacy. Prednisone online was tapered to 60 mg/d. Ten days after admission, she developed neck swelling and hoarseness with pronounced subcutaneous emphysema. Her chest was clear on examination, and the rest of her physical examination was otherwise unremarkable. Her chest radiograph revealed subcutaneous emphysema, pneumomediastinum, and no pneumothorax. On the 11th hospital day, the patient complained of abdominal pain. Examination showed diffuse abdominal tenderness; however, the abdomen was soft with no signs of peritoneal irritation. The patient’s WBC count increased to 23 X 103/^L, with 4% band neutrophils. CT of the abdomen with iodinated contrast medium (Gastrografin; Schering Diagnostics; Berlin, Germany) was nonrevealing. No intraperitoneal air was identified.

A surgeon was consulted on the 12th hospital day; the abdominal pain was attributed to pneumatosis coli. The patient continued to complain of increasing abdominal pain, although her abdominal examination remained unimpressive. The next day, the WBC count increased to 27 X 103/^L, with 8% band neutrophils. On the 14th hospital day, a second abdominal CT with gastrografin was nonrevealing. A chest radiograph and CT image at the level of mediastinum are shown below.

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