Factitious subcutaneous emphysema in young woman

A 33-year-old woman presented to the emergency department be-cause of “pain and swelling in upper extremity” with no history of trauma and fever. She was a known case of diabetes mellitus for 12 years who was under insulin therapy. She had separated from her husband and was living alone. On physical examination, she was afebrile with no abnormality in general examination but had multiple local erythema on her left upper extremity skin with tenderness and crepitation. There were small red macules and papules over sites of erythema which were crusted in some areas. Her left hand x-ray (Figure 1) was significant for subcutaneous emphysema. All labora -tory studies were within normal limits. On further questioning, she had multiple admissions during the previous year with the same complaint and all the diagnostic workups were inconsequential. Since the patient was right-handed and all the presentations were on the left arm, and there were no signs of gas-forming infections or visceral perforations, the skin lesions were attributed to air injec -tion sites and the diagnosis of factitious subcutaneous emphysema was made.Isolated subcutaneous emphysema of an extremity is a rare fin-ding