ABSTRACT
Introduction: In December 2019, the WHO was notified of a novel Coronavirus otherwise known as COVID-19. The disease rapidly spread across multiple borders with a significant toll on loss of human life and a high degree of burden on medical systems across the world. As clinical data, laboratory studies and autopsy reports emerged, the underlying pathophysiological hypotheses evolved to include the eliciting of a hypercoagulable state as being amongst the key factor for the disease progression. In COVID-19 pneumonia, worsening hypoxemia despite maximal ventilator support should prompt evaluation for Pulmonary Embolism (PE) and thrombolytics (tPA) may be a life saver. Here we report 5 cases of severe COVID-19 Pneumonia with presumed pulmonary embolism and worsening hypoxemia successfully treated with thrombolytics with favorable response. Case report 1: 37-year-old Hispanic male with no known medical history presented with 3 days history of symptoms suggestive of COVID-19 Pneumonia including worsening shortness of breath. On admission he was in moderate respiratory distress, saturating at 78 % on room air (RA), which increased to low 90s on 15L oxygen (O2) on non-rebreather mask and subsequently intubated. COVID 19 PCR swab resulted positive and CXR showed characteristics of typical COVID 19 pneumonia with bilateral patchy reticular interstitial opacities. Patient was managed in the for Acute Severe Hypoxemic Respiratory Failure secondary to COVID 19 Pneumonia. Point-of-Care-Ultrasound (POCUS) (Image 1) showing moderately decreased LVEF and signs of RV volume and pressure overload with thrombus-in-situ. Patient developed clinically refractory hypoxia and newly developing shock for which he received a 100mg IV infusion of alteplase along with commencement of nitric oxide to enhance pulmonary vasodilation for better oxygenation with continued lung protective ventilatory support. After the systemic thrombolysis, the patient's oxygen requirement reduced markedly with subsequent POCUS showing return of the normal RV function and absent cardiac thrombus. Case report 2-5: Age range 43-75 years, all admitted with COVID-19 pneumonia and refractory hypoxemia with evidence if VTE. Thrombolytics was given to all the patients with good response and eventually discharge from the hospital. Discussion: Although most patients with COVID-19 predominantly have a respiratory tract infection, a proportion of patients progress to a more severe and systemic disease including but not limited to widespread coagulopathies. Despite covering for anticoagulation, there has been report of incidence of thromboembolic events in such patients. Therefore, it is very important to recognize increasing oxygen requirement and acute deterioration in this patients.
ABSTRACT
Introduction: SARS-CoV-2 infection ranges from self-limiting viral illness to acute respiratory distress syndrome. Diffuse alveolar injury from SARS-CoV-2 increases risk of alveolar rupture. Pneumothorax is a rare complication that has been documented in the literature. Objective: The study aims to investigate the significance of pneumothorax as a complication in patients with previously healthy lungs with acute respiratory failure due to SARS-CoV-2 infection. Methods: This is a case-control study of adult patients without existing lung disease managed for acute respiratory failure who developed pneumothorax as a complication of the disease. Patients with iatrogenic or traumatic pneumothorax, history of chronic lung disease, or previous pneumothorax were excluded. To avoid sample bias from excluding possible false-negatives, the control group (documented SARSCoV- 2 negative) also included patients from the same time period without SARS-CoV-2 testing and a remote unexposed group from a year before. Chi-square analysis was used to determine the relationship between the development of pneumothorax and SARS-CoV-2 infection, with the null hypothesis being no difference in the frequency of pneumothorax among positive SARS-CoV-2 patients and negative SARS-CoV-2 patients. Results: One-hundred-and-thirty charts of patients with symptoms of SAR-CoV-2 were reviewed. Thirty-four patients were documented to be SARS-CoV-2 positive, twelve of which had pneumothorax as a complication of the disease, ninety-one percent of whom were mechanically-ventilated. The control group had ninety-six patients with documented SARS-CoV-2 negative tests, were untested, or part of the historical group. Six patients from the control group had pneumothorax as a complication, two of which were negative for SARS-CoV-2, and three were untested. A Chi-square analysis yielded an X2 statistic of 17.7549 with a p-value of 0.000025.Discussion: Pvalue rejects the null hypothesis in 0.1, 0.05, and 0.01 levels of significance which means that there is a statistically significant difference in the frequency of pneumothorax between the case and control groups. Calculations were done under the assumption that those with negative SARS-CoV-2 tests were indeed free of the virus. There is a probability of underestimation as the tests used may have not been 100-percent sensitive. The four cases of pneumothorax in the control group may have been false-negatives as these patients exhibited imaging findings suggestive of SARS-CoV-2 pneumonia and were likely infected with the virus as well.Conclusion: Pneumothorax is a significant complication in patients without existing lung disease who develop acute respiratory failure and SARS-CoV-2 infection. It should be anticipated and suspected when clinical deterioration occurs especially in mechanically-ventilated patients. .