PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s visual diagnosis competition. It is held annually at the National Conference and Exhibition. This year, all ten finalists will be posted online on and at, one a day with voting opening to AAP Section on Emergency Medicine members thereafter. I hope you enjoy this online-only format, and hope that it will serve to highlight some of the fantastic learning cases that our colleagues submitted this year. It was again very difficult for the panel of judges to select the finalists and I could not have done it without their assistance. As a special treat I’ve included a musical selection form the 1980s as an optional “hint,” and to serve as a soundtrack for your learning.

This PEMPix case was submitted by:

Kasi Eastep, DO, Pediatric Emergency Medicine Fellow along with Michelle Stevenson, MD and Danielle Graff, MD, MSc from Norton Children’s / The University of Louisville School of Medicine

Blown away

A 10-year-old female presented to the emergency department with a one-week history of cough, fever and malaise. Five days prior, she had been seen at another facility where a rapid influenza screen was reportedly positive. Sick contacts had included multiple family members. Her symptoms worsened and  included swelling of the neck and face, sore throat, nonproductive cough, as well as pain and numbness of the left arm. Upon arrival to the Emergency Department, she was placed on a nonrebreather mask for respiratory distress and hypoxemia. She was tachycardic to 134 beats/minute. Her physical exam was significant for trismus, neck rigidity, and submandibular swelling – left greater than right. Lung aeration was diminished bilaterally without wheezing, rales, or rhonchi. Her left arm was tender to light palpation and demonstrated 4/5 strength throughout when compared to the right.

Labs were notable for:
  • Rapid Strep: positive
  • Respiratory Pathogen Panel: positive for influenza A
  • CRP: 18.6 mg/dL
  • ESR: 22 mm/hr
  • Urinalysis: 10 protein, 20 ketones, small blood (1 RBC), trace bacteria
  • Venous blood gas, CBC, Complete Metabolic Panel, and Monospot were obtained and unremarkable
Given the patient’s respiratory distress and physical exam findings, a portable CXR and subsequent CT neck/chest with IV contrast were obtained.

What is the diagnosis?

A. Tension Pneumothorax

B. Boerhaave Syndrome

C. Pulmonary Vein Thrombosis

D. Pneumomediastinum / Pneumorachis

E. Lemierre’s Syndrome

D. Pneumomediastinum / Pneumorachis

This patient suffered from pneumomediastinum complicated by pneumorachis secondary to persistent coughing. Pneumorachis, or air in the spinal canal, is a rare complication of pneumomediastinum. Pneumomediastinum can be either spontaneous or traumatic in origin. In pediatric patients, pneumomediastinum is most often associated with asthma and bronchiolitis. Spontaneous pneumomediastinum is most common in tall, thin adolescent males and newborn infants, though it can. be seen in toddlers and other ages as well. Her esophagram was normal and the history was not significant for emesis making Boerhaave syndrome (effort rupture of the esophagus) unlikely. Less than 20 cases of tension pneumomediastinum have been reported, and this patient did not have tension pneumothorax physiology. Treatment consists of analgesia, rest, avoidance of Valsalva maneuver, incentive spirometry, and in moderate to severe cases of pneumomediastinum high-partial pressure oxygen therapy.
This patient was initially admitted to the PICU on a non-rebreather mask, but was later transitioned to nasal cannula and ultimately room air. Anti-tussive medications were initiated in addition to Amoxicillin for treatment of strep pharyngitis. She did well and was discharged home on hospital day #6.


Alishlash AS, Janahi IA. Spontaneous pneumomediastinum in children and adolescents. In: Redding G, Hoppin AG, ed. UpToDate. Waltham, Mass.: UpToDate, 2018. Accessed May 12, 2020.