Post-traumatic swelling

A 49 year old woman presented to the emergency department with facial swelling (fig 1⇓). She had fallen four days previously, striking her back on a large piece of concrete. After picking herself up she proceeded with her normal activities. The morning after the fall she awoke with swelling of the ankles. The swelling gradually spread throughout her body and four days later it began to compromise her vision. On admission to the emergency department she was generally fit and well, despite the swelling, although she was slightly short of breath on exertion.

On examination she had gross swelling of the chest wall and abdomen extending to the ankles and wrists in the periphery. Breath sounds could be auscultated with a small amount of continuous pressure to the chest wall with the stethoscope. There was a hyper-resonant percussion note and reduced breath sounds on the left side of the thorax, with mild tenderness to percussion on the left posterior thorax over the eighth, ninth, and tenth ribs. Her vision was reduced owing to restricted eye opening, but when her eyelids were opened manually her pupils were equal and reactive to light and accommodation bilaterally. Visual acuity and eye movements were normal in both eyes. All other systems examinations were normal and oxygen saturations on room air were 96%. She underwent computed tomography of the thorax (fig 2⇓)