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JAMA Surgery Clinical Challenge
October 2017

Acute Neck Swelling and Chest Pain After Forceful Coughing

Author Affiliations
  • 1Department of Surgery, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
JAMA Surg. 2017;152(10):976-977. doi:10.1001/jamasurg.2017.2623

A 62-year-old woman presented to the emergency department with severe substernal pain radiating to the left shoulder and back and subsequent swelling of the left side of her neck. She had been recently treated at an outpatient facility for a viral illness with multiple episodes of forceful coughing. There was no recent history of trauma to the neck or chest.

Physical examination revealed normal vital signs and soft tissue swelling over the left supraclavicular area. No overlying skin changes or crepitus were appreciated. Laboratory data revealed leukocytosis (white blood cell count, 18 000/µL; to convert to ×109 per liter, multiply by 0.001). A computed tomographic scan demonstrated extensive edema of the left neck, with fat stranding seen in the subcutaneous tissues extending into the left jugular, carotid, and esophageal spaces (Figure, A). Mediastinal edema and bilateral pleural effusions were also seen on computed tomographic scan (Figure, B). Owing to the concern for esophageal perforation, a barium swallow was performed, showing no extravasation of contrast.

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