• Peng Deng, Yao Chen, Hong Li, and Zhi Wan.
• Emergency Department of West China Hospital Sichuan University, Chengdu, China.
• Medicine (Baltimore). 2018 Dec 1; 97 (51): e13745.

RationaleParaquat is a widely applied contact herbicide that is highly poisonous. About 20% of patients with paraquat poisoning develop pneumomediastinum as a complication with a mortality rate of almost 100%.Patient ConcernsA 15-year-old boy presented with a 1-month history of retrosternal chest pain with no obvious cause. High-resolution computed tomography showed pneumomediastinum.DiagnosesAfter all likely causes of pneumomediastinum were eliminated, the diagnosis of occult paraquat poisoning was made when serum paraquat concentration was revealed at 467.40 ng/mL, despite the patient's denial of ingestion or contact.InterventionsHemoperfusion, intravenous glucocorticoid, and ulinastatin was administered for 3 days with other routine treatment against paraquat poisoning. The serum paraquat concentration decreased to zero.OutcomesDespite the general high mortality and poor prognosis of paraquat poisoning, the patient recovered and was completely asymptomatic at his 3-month follow-up.LessonsParaquat poisoning should be suspected as a differential diagnosis when patients present with pneumomediastinum without recognizable cause.

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