Diagnostic dilemma: One Direction concert left teen with 'crackling' bubbles in her chest

The patient: A 16-year-old girl in Texas

The symptoms: The patient became short of breath after attending a concert by the boy band One Direction. She visited the emergency room the next day and told doctors she had been forcefully screaming during the concert prior to the onset of her breathing difficulties. Her throat wasn't sore, nor was she feeling any chest pain upon arriving at the ER. She had a history of Type 1 diabetes, but had no pre-existing lung conditions.

What happened next: When the doctors examined the patient, her breathing was rapid but otherwise sounded normal. However, when they pressed on the skin of her neck and chest, they detected a popping, crackling sound known as crepitus. This noise is caused by small air bubbles that escape from the lungs and become trapped under the skin. An X-ray revealed the extent of the air bubbles: They appeared behind her throat, between her lungs and the walls of her chest, and around her heart.

The diagnosis: The doctors determined that the patient's enthusiastic vocal appreciation of One Direction had caused a mild form of lung collapse, which forced air into tissues outside of her lungs. The doctors conducted a computed tomography (CT) scan but did not detect any physical tears in her respiratory tract that could account for the escaped air bubbles.

The treatment: The patient was admitted to the hospital for observation and placed on a breathing apparatus that delivered 100% oxygen through a mask. The next day, a chest X-ray showed that her condition had not worsened, so hospital physicians decided she was in no danger and could go home. After she was discharged, there were no follow-up visits or treatments.

What makes the case unique: Forceful screaming at a pop concert leading to multiple lung disorders is "extraordinary," the emergency room doctors wrote in a report of the case.

Air escaping into the chest is known as pneumothorax, while air collecting around the heart and in the throat is known as pneumomediastinum and pneumoretropharyngeum, respectively. A small number of prior medical reports described patients who developed pneumomediastinum from prolonged shouting, the doctors wrote. However, the simultaneous and spontaneous development of all three conditions, as experienced by this teenage patient, "has yet to be described in medical literature," the doctors noted in the report.

Each of these conditions rarely appears in people who have no preexisting lung issues. Known triggers include respiratory infections, complications from asthma and trauma from sudden changes in air pressure. In some instances, intense activities — such as weight lifting or flying military aircraft — can cause dramatic pressure changes in the lungs that lead to lung collapse.

"This particular case suggests that forceful screaming during pop concerts should be added to that list," the doctors wrote.