ABSTRACT
TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 pneumonia can result in complications such as ARDS, septic shock, thromboembolic events, and kidney failure. Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema are rare complications. CASE PRESENTATION: A 72-year-old African American female presented with a four day history of dyspnea. She was tachypneic with respiratory rate of 25/min with O2 saturation of 67% on room air, oxygen therapy via nonrebreather mask improved the O2 saturation to 92%. PCR test for SARS-CoV-2 was positive. Laboratory studies revealed a D-dimer-1121 ng/ml, C-reactive protein-15.97mg/dl, ferritin-356.8 and lactate dehydrogenase-337 U/L. Chest X-ray showed focal areas of interstitial and alveolar opacities. A CT scan of chest showed multiple focal ground glass opacities in the bilateral lung fields. She was treated with dexamethasone, remdesivir and supplemental oxygen. Two days later she became more hypoxic and chest X-ray showed increased interstitial opacities and a small pneumomediastinum. She was placed on high flow nasal cannula oxygen therapy. On the fourth day, her condition acutely worsened and she was emergently intubated without any complications and placed on mechanical ventilation with tidal volume of 6ml/kg ideal body weight. Post intubation chest-X-ray showed extensive pneumomediastinum, subcutaneous emphysema and right sided pneumothorax. Bilateral chest tubes were placed. Ultimately the patient passed away. DISCUSSION: COVID-19 pneumonia presents with a wide spectrum of symptoms, ranging from febrile illness to complications like ARDS, respiratory failure, and septic shock. Spontaneous pneumothorax, subcutaneous emphysema and pneumomediastinum are relatively rare complications. We presented a case of COVID-19 pneumonia who developed these complications while getting appropriate treatment. COVID-19 pneumonia can cause diffuse alveolar damage, desquamation of pneumocytes and cellular fibromyositis [1,2]. Increase in alveolar pressure by coughing or Valsalva maneuver can cause marginal alveoli to rupture and leak air into the interstitial space. The air then dissects between the perivascular and the peri-bronchial sheath into the mediastinum, pleural space and subcutaneous tissue causing pneumomediastinum, pneumothorax and subcutaneous emphysema respectively. Higher level of LDH is associated with increased risk of air leak from the lungs [3]. Small pneumothoraces can resolve on their own, but larger require chest tubes. Pneumomediastinum and subcutaneous emphysema are usually self-limiting benign conditions which resolve with bed rest, analgesics, and oxygen therapy [3]. CONCLUSIONS: Sudden deterioration in the oxygenation in COVID-19 patient should prompt clinicians to think of possible air leakage. Management of pneumomediastinum, subcutaneous emphysema and smaller spontaneous pneumothorax is conservative but large and tension pneumothoraces require chest tube. REFERENCE #1: Quincho-Lopez A, Quincho-Lopez DL, Hurtado-Medina FD. Case Report: Pneumothorax and Pneumomediastinum as Uncommon Complications of COVID-19 Pneumonia-Literature Review. Am J Trop Med Hyg. 2020;103(3):1170-1176. doi:10.4269/ajtmh.20-0815 REFERENCE #2: Shan S, Guangming L, Wei L, Xuedong Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19: case report and literature review. Rev Inst Med Trop Sao Paulo. 2020;62:e76. Published 2020 Oct 9. doi:10.1590/S1678-9946202062076 REFERENCE #3: Elhakim TS, Abdul HS, Pelaez Romero C, Rodriguez-Fuentes Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review. BMJ Case Rep. 2020;13(12):e239489. Published 2020 Dec 12. doi:10.1136/bcr-2020-239489 DISCLOSURES: No relevant relationships by Prakash Adhikari, source=Web Response No relevant relationships by Nikhil Madala, source=Web Response