therefore , the purpose of this work is to discuss possibilities and mechanisms of serious and grave multiple complications associated with purulent meningitis ( pneumorrhachis ) . based on the studied case , conclusion and recommendations that would animate the debate on the topic
he was admitted in the emergency department for cephalalgia , fever , and frequent easy vomiting lasting 1 week duration .
symptoms were associated to a puffiness of the face and dyspnea of level i according to sadoul classification . at admission ,
the blood pressure was 120/70 mmhg with a heart rate of 80 beats / min and a respiratory frequency of 24 cycles / min . the neurological examination objectified signs of meningeal irritation without any motor and sensory deficit .
the pleuropulmonary examination found subcutaneous emphysema in the top part of the thorax and upper limbs extending to the cervical region and the face . associated air effusion syndrome was not evidenced .
afterward , a lumbar puncture was performed and revealed a blurred liquid with predominant polynuclear neutrophils ( 80% ) .
g / l ( with concomitant glycemia of 1.20 g / l ) ; total albumin level was 0.98
g / l , and the classical cerebrospinal fluid ( csf ) gram s stain and culture was negative .
the immunochemistry study of lumbar puncture was in favor of meningitis diagnosis , which oriented to start the antibiotherapy .
the routine biological and hematological studies included blood cells count and blood culture , ionogram , and sedimentation rate were found to be normal .
the patient was treated using adequate antibiotherapy consisting of 2.0 g of ceftriaxone every 12 h. ceftriaxone dose was maintained at the meningitis rate of 100 mg / kg / day .
the thorax x - ray showed a pneumomediastinum in the left paratracheal border along the left edge of the heart ; the image also showed subcutaneous emphysema without associated pneumothorax [ figure 1 ] .
evermore , thorax ct scan confirmed all abnormalities described in the thorax x - ray and revealed the presence of air collection in the spinal canal between c7 and d6 levels [ figure 2 ] .
the laryngoscopy , bronchoscopy , and digestive opacification did not show any abnormality in the respiratory - digestive tracts .
these invasive gestures were achieved under general anesthesia without remarkable event . the clinical evolution within 48 h was marked by the occurrence of apyrexia , coupled with disappearance of the subcutaneous emphysema and the meningeal steepness .
however , the neurological status of the patient worsened gradually ; a paraparesis occurred and was followed by a tetraparesis .
the patient started with presenting neurovegetative disorders with hemodynamic instability which was in favor of central affection .
afterward , a spinal magnetic resonance imaging ( mri ) was performed and showed a cervical medullary edema extending from c2 to c6 without any sign of spinal cord compression .
this result was consistent with a general clinical profile of acute transverse myelitis [ figure 3 ] .
the hemodynamic support consisted initially of administrating vasoactive drugs and dopamine then adrenaline since nor adrenaline was not available .
the patient died within 15 days with a profile of vasoparalysis resistant to vasoactive drugs .
facial thoracic x - ray showing the pneumomediastinum with a form of a left bordered paratracheal along the left edge of the heart and subcutaneous emphysema the thoracic computed tomography ( ct ) scan in axial slice of the dorsal spine showing a lateral pneumorrhachis , pneumomediastinum , and cutaneous emphysema spinal magnetic resonance imaging ( mri ) in sagittal view in t1 ( a ) and t2 ( b ) showing medullary edema extending from c2 to c6
initially described by gordon and hardman , in 1977 , pneumorrhachis is defined as the presence of air in the spinal canal , either in the intradural and/or extradural spaces .
it is a very rare clinical entity and mostly asymptomatic ; hence most probably underdiagnosed .
the first type is associated with degenerative , malignant , inflammatory , and infectious diseases , while the last variety is generally associated to epidural anesthesia , lumbar puncture , spinal surgery , or after a chest tube insertion .
the most reported hypothesis in the literature consists of a mechanism involving an increased intrabronchial pressure that leads to alveolar rupture when enough gradient pressure is produced .
afterwards , the air cumulated in the mediastinum separates the mediastinal pleura from the aorta and the parietal pleura from the rachis , and penetrates the epidural space through the conjugate foramina .
additional mechanisms might result from severe asthma attack , coughing , or other efforts while the glottis is closed .
more rarely , spontaneous pneumorrhachis occur after grave vomiting efforts that our patient expressed ; he manifested vomiting secondary to purulent meningitis .
the association of spontaneous pneumorrhachis with a pneumomediastinum is quite rare and restricted to very few cases in the literature . to the best of our knowledge ,
the association of spontaneous pneumorrhachis with pneumomediastinum and transverse myelitis originating of purulent meningitis was never described in the literature . in our patient
, we believe that the occurrence of a tetraparesis is not secondary to a spinal cord compression caused by the pneumorrhachis itself , since the level of the intramedullary hypersignal in the mri images and the clinical profile are supporting the diagnosis of a transverse myelitis associated to pneumorrhachis . this association was never described in earlier literature .
firstly , both pneumorrhachis and transverse myelitis present are distinct complications of purulent meningitis evolving independently : pneumorrhachis was caused by alveolar rupture induced by thoracic hyper pressure provoked on its turn by emesis , while transverse myelitis is an independent complication of meningitis related to infectious and/or inflammatory disorders .
secondly , pneumorrhachis and transverse myelitis have been closely laid : the pneumorrhachis has facilitated and/or anticipated the occurrence of spinal cord edema through inflammatory mechanisms or by compromising the venous drainage of the epidural veins .
finally , both pneumorrhachis and transverse myelitis have been probably caused by gas - forming germs .
nevertheless , this last hypothesis might be excluded considering the important size of the pneumomediastinum and the absence of typical signs of infectious mediastinitis .
these consist of endoscopy exploration and digestive opacification excluding any esophageal rupture , tracheal branches perforation , or laryngeal fissure the ct scan remains the diagnostic tool of choice .
however , x - ray radiography is helpful for initial exploration allowing the early detection of pneumorrhachis .
most reports considered the benign course of spontaneous pneumorrhachis which is usually reabsorbed spontaneously and completely without causing any symptoms , and does not recur .
indeed , yoshida et al . reported three observations of compressive pneumorrhachis complicated by lumbar radiculopathy , which were resolved spontaneously .
however , in cases of secondary pneumorrhachis , prophylactic antibiotherapy is recommended to prevent meningitis . in case of symptomatic pneumorrhachis
thus , raynor and saint - louis described a case of radicular compression secondary to a pneumorrhachis that occurred 10 days after a lumbar disk surgery ; in this case , the evolution was favorable using corticosteroid therapy .
exceptionally , spinal surgery is required for releasing the spinal cord from the air bubbles . to date
, there are no guidelines for the treatment of this clinical entity due to its extreme scarcity . in general
in addition , the control of infection is more important for the prognosis of the patient .
the association of spontaneous pneumorrhachis with pneumomediastinum and transverse myelitis was never reported in the literature .
therefore , particular care must be undertaken when dealing with patients of such pathological profile .
further reports might better lighten the mechanisms underlying this pathological association as well as the optimal treatment .
 pneumorrhachis is the presence of air in the spinal canal ; mostly , it has an iatrogenic origin . 
 the association of this entity with spontaneous pneumomediastinum without any pneumothorax is rarely reported in the literature . 
 the spontaneous resorption is the usual evolution . 
 the association to acute transverse myelitis is discussed by the authors.the patient is a 21-year - old male with pneumorrhachis associated to a spontaneous pneumomediastinum was admitted at the emergency department for bacterial meningitis . 
 the antibiotherapy has marked the clinical profile by disappearance of the meningeal signs in the 48 h after admission . 
 in contrast , the neurological symptoms were of marked aggravation by appearance of a tetraparesis with a respiratory distress syndrome having required artificial ventilation . 
 the computed tomography ( ct ) scan showed a typical hypodensity corresponding to paramedullary air extending to several thoracic segments . 
 the spinal magnetic resonance imaging ( mri ) showed a high cervical medullary edema without signs of compression . 
 the patient died within 15 days with a profile of vasoparalysis resistant to vasoactive drugs.pneumomediastinum associated to pneumorrhachis and transverse myelitis complicating purulent meningitis is a rare entity . 
 although the usual evolution is favorable , the occurrence of serious complications is possible . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSIONS