A 21-year-old female was admitted to the casualty at 2:00AM. She complained of severe pain from the face to the chest. She also complained of dyspnea and difficulty in opening her mouth. A plain computed tomography (CT) scan revealed gas in the nasopharynx, temporomandibular joint, pharynx, larynx, and tracheal bifurcation area (Figure 1A). From her first interview, she experienced no traumatic episodes, so gas gangrene was first considered. We planned emergency drainage; however, contrast-enhanced CT revealed no enhancement around the emphysema (Figure 1B and C), so we again checked her history from the attendants. According to their interview, they took a video of their sexual scene 4 hours before medical consultation. During filming, an anal plug was inserted into her mouth, and aggressive movement was done. Endoscopy revealed a wound on the posterior wall of the pharynx (Figure 2). Therefore, an anal plug made a laceration on the posterior wall of the pharynx, and the patient’s sexual exercise and vigorous breathing during the filming caused extensive emphysema. The patient was hospitalized, and antibiotics were administered. Symptoms gradually ceased, and a CT scan 2 days later showed that the emphysema had decreased. The patient was discharged from the hospital on the fifth day without worsening symptoms. After 4 weeks, her pharyngeal wound had healed, and the emphysema had disappeared on CT (Figure 3).

Because gas gangrene progresses rapidly and can be fatal, immediate surgical intervention is required. In this case, an accurate medical history was difficult to obtain. Enhanced CT and accurate information from the attendants made an accurate diagnosis and avoided unnecessary surgery.