DCS symptoms without diving?!?

[Patoloco]

Please bear with me, this is a nicely detailed history from a friend and I want Dr. Decompression to have a chance to weigh in on the full story. If anyone has additional diagnostic test suggestions (MRI of neck was one idea i had), or treatment ideas, please chime in.

Demographics: 40 yr old fit captain who runs a live aboard dive/education business in the summer and skis in the winter. No smoking, social drinking. No history of pulmonary/cardiac problems. No family history either. Positive history of decompression sickness (the bends), treated in a chamber at least once in the past.

Tests done so far (all neg):
1. esophageal echo
2. CT chest with contrast

His story:
....I have mostly stopped diving completely.This summer, I had a real need for making a video this past summer of divers in training for marketing purposes. I decided to allow myself one dive this summer, to 10 feet of water, for 15 minutes, and with a 5 minute safety stop at 5 feet and a really slow ascent.

With all these precautions, I still had DCS type symptoms several days later (not within the first 24 hours). My symptoms were:
1. pain in my chest on the right side,
2. pain and unusual sensation in my neck and arm
3. sense of fullness in neck.
Due to logistics, I choose not to seek hyperbaric treatment for the symptoms;they eventually mostly subsided in a few days and NSAIDS worked well. This was the ONLY dive done in over a year, including any free dives greater than 6 feet in depth.

In the last 1-2 years, I have had several within-limits DCS hits and I suspect there is some other problem than lack of decompressing that is going on.

Disturbingly, the symptoms occur without diving. When lecturing or if I speak loudly for a period of time, I notice pain for a few days in my chest and neck. After one lecture, I looked in the mirror and the right side of my neck was visibly swollen. It creates pain in a specific spot on the right side of my chest, my arm can go numb, and in general it sucks.

Other inciting events:
1. blow into the didgeridoo
2. holding my breathe. I have found that I can only free dive if I let a significant bit of the air out of my lungs before descending. Last year I got seriously “bent” with skin bruising, severe chest pain, and numbness from a breath hold dive to 60 feet. Although theoretically possible, it should not have happened since it was 1 dive without compressed air or anything.
3. If I drink several fizzy soda drinks, it seems to increase the discomfort in my neck.

Worse, in August I went snorkeling for a couple of hours and used extreme self discipline in not doing any free dives, not even to a couple of feet, just breathing through the snorkel at the surface. A short time after leaving the water, I thought that I was coming down with a cold, I had a terrible time swallowing and my neck and throat hurt. I subsequently never developed a cold though.

Last Winter, while living in Aspen, I had a cold and was coughing a lot. I went out skiing upon feeling better and went up to the top of the cirque in snowmass (11,000 feet). I coughed in the cold air and my chest started to feel funny (numbness in my arm, chest pain). Upon returning home with ongoing chest pain, I went to the emergency room. They ran a battery of tests (yet another chest x-ray, blood work, ecg) and no sign of any cardiac problems.It all resolved in a few days. Even an esophageal echo was normal.

Last December I had a full CT scan with contrast done of my chest; it came back with a clear bill of health. The pulmanologist said that I was the healthiest lung patient he had ever treated...

I feel what I develop is subcutaneous emphysema. The signs and symptoms all seem to match wikipedia references, except there are no crunchy or pop sensations. I currently have symptoms (chest pain on right side, fatigue feeling in arm, fullness in neck) to a slight degree that I can exacerbate by simply talking loudly for 15 minutes.

[TSandM]

Well, just based on what you have told us, I would be willing to say that you are not experiencing subcutaneous emphysema. The hallmark of that is a crunching or popping sensation when the tissue full of air is touched. The other symptoms (heaviness, pain, etc.) are extremely nonspecific, and should not point you to a definite diagnosis at all.

I think, if you develop the swelling in your neck again, you should have someone photograph it. There are not that many structures in the neck, and very few which are likely to increase in size and resolve on a repeated basis.

It sounds as though you are developing your symptoms whenever your intrathoracic or intraabdominal pressure is increased. This CAN aggravate disc problems (but disc issues would not cause visible swelling). Increased pressure also can cause an impediment to venous or lymphatic drainage from the head -- in a WAG sort of way, I could imagine a lymphocele at the base of your neck on the right that, when it's engorged, is causing pressure on the brachial plexus (the nerves going to your right arm from your neck). Depending on how far up the cuts on the chest CT went, they might not have seen something like this.

Photographs of swelling would be VERY useful for your doctors.

[Dr Deco]

Hello Patoloco:

Despite mentioning DCS in your post, you assuredly do not have DCS of the type caused by excess gas loading. The dives that you performed could simply not load sufficient inert gas to do this. In addition, you do not get DCS “several days later.”
Something like a breath hold is another story, but you do not indicate doing anything of the sort. TS and M has given other logical possibilities.

Dr Deco

[Duke Dive Medicine]

You may want to consider having someone else look at the CT (the actual images, not the narrative report).

[couv]

I'm not a doctor, and I can't even make a WAG, so here is a question for those that are. Is it possible the OP is having an allergic reaction to a piece of gear such as a silicone or rubber mouthpiece?