Hrev_master Emergency Care Journal 2025; volume 21:13942 Things are not always what they seem Massimo Barakat, Stefania Sartoni Galloni, Nilde Di Paolo Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Bologna, Italy Figure 1. Chest X-ray. Figure 2. Coronal CT scan of the chest showing severe pulmonary emphysema and large amount of free air in the mediastinum (A). Coronal (B) and axial (C) CT scan of the abdomen showing abun- dant and widespread accumulation of air in the intestinal walls and large amount of free air in the abdomen. Question Given the patient’s history and CT scan result, which is the most likely diagnosis? 1. Acute bowel ischemia with intestinal perforation and pneumo- mediastinum 2. Bowel perforation with pneumomediastinum 3. Pneumatosis cystoides intestinalis with benign pneumoperi- toneum and pneumomediastinum 4. Bowel inflammation with intestinal perforation and pneumo- mediastinum A 80-year-old woman, heavy ex-smoker (60 pack-years) affected by chronic obstructive pulmonary disease (COPD), presented to the emergency department with worsening dyspnea in the previous three hours, metabolic alkalosis (pH 7.55, pO2 33 mmHg, pCO2 34 mmHg, HCO3 30 mmol/L, lactates 3.3 mmol/L) and persistent epi- gastric pain for one week. She was under treatment with low-dose aspirin, metoprolol, atorvastatin, pantoprazole, ramipril, salmeterol and fluticasone propionate, tiotropium bromide, allopurinol, benser- azide, diazepam, furosemide. On physical examination, she present- ed with tachypnea (30 beats/min) and reduced peripheral oxygen saturation on room air (83%); her remaining vital signs were normal and there were no signs of peritonism. Blood tests revealed an increase of white blood cell (11.07 x 109/l) and neutrophil (9.73 x 109/l) count, glycemia (217 mg/dl), C-reactive protein (2.49 mg/dl; normal values < 0.5 mg/dl) and B-type natriuretic peptide (259 pg/mL; normal values <100 pg/mL) levels. Estimated glomerular filtration rate was moderately to severely decreased (36 mL/min/1.73 m2). Remaining blood exams (including hepatic func- tion and coagulation time) were normal, in particular lactate dehy- drogenase levels (200 U/L; normal values < 248 U/L). Chest X-ray showed a small amount of abdominal free air below the right hemidiaphragm (Figure 1, red arrow) and subcutaneous emphyse- ma in the right lateral abdominal wall (Figure 1, white arrow). A subsequent thoraco-abdominal comupted tomography (CT) scan documented severe pulmonary emphysema (Figure 2 A), abundant and widespread accumulation of air in the intestinal walls (Figure 2 B and C), large amount of free air in the mediastinum (Figure 2 A) and abdomen (Figure 2 B and C). Correspondence: Massimo Barakat, Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Pietro Albertoni n° 15, Bologna, Italy Tel.: +390512144327 E-mail: massimo.barakat@gmail.com Key words: pneumatosis cystoides intestinalis, chronic obstructive pulmonary disease, pneumoperitoneum, pneumomediastinum, com- puted tomography. Contributions: MB conceptualized and wrote the manuscript. SSG drafted the report of the thoraco-abdominal computed tomography scan. NDP drafted the report of the chest X-ray. Conflicts of interest: the Authors declares no conflict of interest. Funding: none. Availability of data and materials: all data and materials are included in this published article. Ethics approval and consent to participate: as this was a descriptive case report and data were collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: the patient provided consent for the access to medical records at the time of admission. Received: 1 May 2025. Accepted: 8 May 2025. Early view: 16 June 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13942 doi:10.4081/ecj.2025.13942 [Emergency Care Journal 2025; 21:13942] [page 33] Answer Pneumatosis cystoides intestinalis with benign pneumoperitoneum and pneumomediastinum is the correct answer. After two weeks of conservative management (ceftriaxone 2 g iv daily and metronida- zole 500 mg Q8H for 7 days, intestinal rest with total parenteral nutrition and oxygen), a CT scan documented a complete resolu- tion of abdominal findings and pneumomediastinum. The patient was discharged after 16 days of recovery in good clinical condi- tion. Pneumatosis cystoides intestinalis is characterized by the presence of multiple gas-filled cysts within the submucosa or sub- serosa of the gastrointestinal tract.1,2 It is a rare disease affecting approximately 0.03% of the adult population.3,4 It can be idiopathic (15%) or secondary (85%) to various predisposing factors, includ- ing pulmonary conditions (COPD, asthma), gastrointestinal pathologies (inflammatory bowel diseases, intestinal occlusion), scleroderma, mechanic ventilation and drugs (steroids, immuno- suppressants, chemotherapy agents).5 Patients with COPD may experience increased intraalveolar pressure (for example caused by coughing), which can led to alveolar rupture, air dissection within the mediastinum and the abdomen and air trapping in the bowel wall to form cysts.1,6 In the absence of signs of any life-threatening conditions (such as peritonitis, sepsis, acidosis and portal venous gas on CT scan images), conservative management (antibiotics, intestinal rest and oxygen) is warranted because in these cases pneumatosis cystoides intestinalis is a self-limited process.3,7,8 References 1. Iida A, Naito H, Tsukahara K, et al. Pneumatosis cystoides intestinalis presenting as pneumoperitoneum in a patient with chronic obstructive pulmonary disease: a case report. J Med Case Rep 2017;11:55. 2. Scowcroft H, Sharma P. Pneumatosis cystoides intestinalis associated with novel cancer therapy use. ANZ J Surg 2022;92:276-7. 3. Logue G, Chaudhry M. Pneumatosis cystoides intestinalis pre- senting as pneumoperitoneum in a patient with chronic obstructive pulmonary disease. BJR Case Rep 2023;9:20230020. 4. Ma W, Zhang C, Sun MW, Cai B. Pneumatosis cystoides intestinalis: A case report and literature review. Asian J Surg 2023;46:2581-2. 5. Wang YJ, Wang YM, Zheng YM, et al. Pneumatosis cystoides intestinalis: six case reports and a review of the literature. BMC Gastroenterol 2018;18:100. 6. Pata F, Di Saverio S. Pneumatosis cystoides intestinalis with pneumoperitoneum. N Engl J Med 2019;380:e17. 7. Kotek J, Dušek T, Sirový M, et al. Pneumatosis cystoides intestinalis as a rare cause of non-surgical pneumoperitoneum. Rozhl Chir 2023;102:214-8. 8. Dantas E, Coelho M, Cardoso C, Oliveira AP. A rare cause of lower gastrointestinal bleeding: Pneumatosis cystoides intesti- nalis. Gastroenterol Hepatol 2022;45:555-6. Images in emergency [page 34] [Emergency Care Journal 2025; 21:13942]