Nuno Miguel Preto Gomes1, Pedro Matos1, Patricia Pereira Amoedo1, Andre Cerejeira1, Luis Lemos2, Maria Joao Cruz1, Paulo Santos1, Filomena Azevedo1
1 From the Department of Dermatovenereology, Centro Hospitalar Universitário de São João EPE, Porto, Portugal
2 Department of Internal Medicine, Centro Hospitalar Universitário de São João EPE, Porto, Portugal

Date of Web Publication2-Nov-2022

Correspondence Address:
Nuno Miguel Preto Gomes
From the Department of Dermatovenereology, Centro Hospitalar Universitário de São João EPE, Porto
Portugal

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijd.ijd_122_21

How to cite this article:
Preto Gomes NM, Matos P, Amoedo PP, Cerejeira A, Lemos L, Cruz MJ, Santos P, Azevedo F. Cryosurgery-induced pneumomediastinum in a young woman with hidradenitis suppurativa. Indian J Dermatol 2022;67:458-9
How to cite this URL:
Preto Gomes NM, Matos P, Amoedo PP, Cerejeira A, Lemos L, Cruz MJ, Santos P, Azevedo F. Cryosurgery-induced pneumomediastinum in a young woman with hidradenitis suppurativa. Indian J Dermatol [serial online] 2022 [cited 2022 Nov 7];67:458-9. Available from: https://www.e-ijd.org/text.asp?2022/67/4/458/360309

Sir,

Hidradenitis suppurativa (HS) is a dermatosis characterized by nodules, abscesses, and sinus tracts in the apocrine gland-bearing areas. Surgical treatments are increasingly recognized as valuable in HS treatment,[1] namely cryosurgery for the treatment of inflammatory nodules[2],[3] and sinus tracts.[4],[5]

We report the case of a 19-year-old obese female followed for axillary, groin, and inframammary HS Hurley grade III for 7 years, previously been treated with multiple antibiotics, oral contraceptives, metformin, and prednisolone, and currently under adalimumab for 2 years.

The patient was admitted for the treatment of a recalcitrant right inframammary fistula draining pus for at least 6 months. The magnetic resonance image showed a limited subcutaneous fistula with 2 cm. After topical anesthesia, the left extremity of the fistula was catheterized with an 18-G needle and passed through until the right extremity. Then, cryoinsufflation was performed with liquid nitrogen, with a total of two freezing cycles of 20 s each (5-s pulse followed by 1-s pause) by using a CRY-AC® spray. Immediately after the procedure, the patient started complaining of dyspnea with a thoracic pressure. She was otherwise asymptomatic and clinically stable, with normal pulmonary auscultation and hypophonetic heart sounds. A thorax X-ray frontal view revealed subcutaneous emphysema, and the computed tomography (CT) scan confirmed an extensive thoracic and cervical tissue emphysema on the right inframammary region and a pneumomediastinum, without appreciable pneumothorax [Figure 1] and [Figure 2]. She was admitted to the intermediate care unit for surveillance and evolved well, with spontaneous resolution of dyspnea in 2 days. The CT scan performed 6 days later showed a global improvement of the emphysema as well as a significant reduction of the pneumomediastinum. The treated fistula healed in 20 days without further purulent discharge and no recurrence after 1-year follow-up. No further complication of the procedure has been noted.

Figure 1: The CT scan transverse plane at the level of the medium heart showed thoracic tissue emphysema on the right inframammary region and pneumomediastinum anterior to the left ventricle

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Figure 2: The CT scan transverse plane at the level of the trachea bifurcation showed extensive thoracic tissue emphysema and pneumomediastinum anterior to the aorta, without appreciable pneumothorax

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Cryosurgery is a widely available technique that has been rarely used to treat HS.[2],[4],[5] When its use was reported in HS, it was mostly in the form of cryoinsufflation, which involves injecting liquid nitrogen through an ordinary needle directly into HS tracts.[1],[4],[5],[6] Twenty-two patients treated with cryosurgery reported complications such as ulcerations,[2] infections,[2] vagal reactions,[4] or local pain.[3]

This case highlights the need for caution while performing cryosurgery to treat HS nodules or fistulas. Although other complications were not noted, the gas embolism provoked significant emphysema and pneumomediastinum, which can be life-threatening. In fact, this is an exceedingly rare complication, mainly because the quick freezing of any internal path of the fistula prevents the spreading of the air to adjacent tissues. Although it provides a benign resolution and a good surgical outcome, the mentioned complications may be a major disadvantage of this technique, mainly when performing cryosurgery in the inframammary area. The long duration of HS (7 years) may be a risk factor for unrecognized sinus tracts and multiple areas of tissue weakness that predispose to tissue emphysema and pneumomediastinum, even if they are not noted in imagiological exams. Cryoinsufflation may be safer for HS patients with shortly-lived nodules and fistulas, with inguinal or axillary lesions, and if performed concomitantly with ultrasonographic guidance and general anesthesia.[3],[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

   References 
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    3.Molina-Leyva A, Salvador-Rodriguez L, Martinez-Lopez A, Cuenca-Barrales C. Effectiveness, safety and tolerability of drainage and punch-trocar-assisted cryoinsufflation (cryopunch) in the treatment of inflammatory acute fluid collections in hidradenitis suppurativa patients. J Eur Acad Dermatol Venereol 2019;33:e221-3.  
    4.Pagliarello C, Fabrizi G, Feliciani C, Nuzzo SD. Cryoinsufflation for Hurley stage II hidradenitis suppurativa: A useful treatment option when systemic therapies should be avoided. JAMA Dermatol 2014;150:765-6.  
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  [Figure 1], [Figure 2]