Spontaneous air in the retropharyngeal space presenting with hypoxemia and neck pain in a child with neuroblastoma: A case report

SummaryA 9-year-old white male with a stage IV neuroblastoma of thorax since 4 years of age presented to the routine clinic visit with several days history of nonproductive cough, neck pain and progressive dyspnea. The oxygen saturation was 87%. His head and neck exam was insignificant and there was no crepitus or tenderness to neck palpation. Chest X-ray was normal but neck X-ray showed a strip of air in the retropharyngeal space. Last transplant was allogeneic BMT 9 months back followed by grade-III chronic graft versus host disease of skin and gut. The CT scan of neck and chest confirmed pneumomediastinum with retropharyngeal air and bilateral faint pulmonary infiltrates. Systemic steroids were added to the treatment to stabilize his respiratory condition. After 10 days of ICU stay his condition improved and he was discharged home. Repeat neck X-ray after 14 days showed near complete resolution of retropharyngeal air.From the clinical, radiological picture as well as therapeutic response to steroids the most likely diagnosis was cryptogenic organizing pneumonia formerly known as “bronchiolitis obliterans with organizing pneumonitis” (BOOP). Pneumomediastinum is reported in the literature as a rare cause of spontaneous air in the retropharyngeal space. Usually pneumomediastinum is a terminal event but in our patient it was a presenting symptom of BOOP. We also report a subtle presentation of BOOP and complete resolution with steroids.