Extensive Pneumomediastinum Associated with Extreme Anorexia Nervosa

Background: Spontaneous pneumomediastinum (SPM) is a rare complication of anorexia nervosa and severe malnutrition. Chronic starvation causes alveolar wall weakening and respiratory muscle atrophy, predisposing to alveolar rupture with air dissection along fascial planes.

Case Presentation: An 18-year-old woman with extreme anorexia nervosa presented with progressive bilateral leg weakness and inability to ambulate. She was hypothermic (34.8°C), bradycardic (50 bpm), and hypotensive (91/62 mmHg). Initial chest radiography showed radiolucent streaking consistent with SPM, which was not initially recognized.

Imaging Findings: Contrast-enhanced CT of the neck, chest, abdomen, and pelvis revealed extensive pneumomediastinum extending into the neck and shoulders, accompanied by epidural pneumatosis, bilateral pneumothoraces, and severe diffuse skeletal muscle atrophy. No esophageal perforation or free intraperitoneal air was identified. Head CT demonstrated enophthalmos and marked masticatory muscle atrophy. The patient was managed conservatively with nutritional rehabilitation and supportive care, and was discharged after two weeks.

Conclusion: Extreme starvation can produce diverse and striking multisystem radiological findings. This case illustrates SPM and other imaging manifestations of severe anorexia nervosa, underscoring the role of multimodality imaging in detection, characterization, and risk stratification of this under-recognized entity.