A Rare Chest Presentation of Inflammatory Bowel Disease: Spontaneous Pneumomediastinum in Crohn’s Disease

Abstract

We report the case of a 46-year-old man with long-standing Crohn’s disease who presented with acute central chest discomfort and dyspnea, following an episode of forceful vomiting. His gastrointestinal symptoms had been mild and self-managed, with no prior history of fistulizing disease. Physical examination revealed mild central chest tenderness and shallow breathing without overt respiratory distress. Initial chest radiography demonstrated mediastinal air consistent with pneumomediastinum. Subsequent contrast-enhanced CT scans of the chest, abdomen, and pelvis revealed free air tracking from a thickened terminal ileal segment through the retroperitoneum into the posterior mediastinum, suggesting a contained microperforation with a developing fistula. Laboratory workup showed mild elevation of inflammatory markers, with otherwise stable hematologic and metabolic parameters. The patient was admitted for conservative management, including supplemental oxygen, bowel rest, intravenous fluids, analgesia, and targeted antibiotics. Serial imaging and clinical monitoring demonstrated gradual resolution of mediastinal air without progression to pneumothorax or abscess. Gastroenterology follow-up focused on optimization of Crohn’s therapy to prevent recurrence. This case underscores the rare but clinically significant occurrence of pneumomediastinum secondary to fistulizing Crohn’s disease. Early recognition through imaging, careful monitoring, and multidisciplinary management allowed for a favorable outcome. Awareness of subtle respiratory manifestations in Crohn’s disease is essential to prevent misdiagnosis and guide appropriate care.