Managing Post COVID-19 Patient with Breathlessness.

Background: Chronic respiratory disease may be associated with severity of coronavirus disease 2019 (COVID-19) infection. We review a case of chronic obstructive pulmonary disease (COPD) patient who developed acute breathlessness post COVID-19 infection, also focusing on the diagnostic approach. Case: A 69-year-old gentleman with background history of COPD GOLD D and ischemic heart disease was admitted with severe COVID-19 infection. He required high-flow nasal cannula upon presentation. A computed tomography pulmonary angiography (CTPA) thorax at day 10 of illness revealed moderate organizing pneumonia (OP) with emphysematous changes, without pulmonary embolism. He received oral baricitinib and intravenous methylprednisolone for 3 days, which was then followed by tapering prednisolone starting dose of 1 mg/kg/day (60 mg/day) with reduction of 10 mg prednisolone every 3 days. COPD pharmacotherapy was optimized with early utilization of dual bronchodilators and inhaled corticosteroid was withheld. He underwent inpatient pulmonary rehabilitation and was discharged with home oxygen therapy. Unfortunately, he was re-admitted after 2 weeks with shortness of breath and fever for 3 days. Blood results revealed leucocytosis with raised C-reactive protein. A repeat CTPA showed increase reticulations and crazy paving pattern with reduction in lung volume. Multidisciplinary team discussion concluded it as interstitial pneumonia with COVID-19 OP and fibrosis progression. Prednisolone was stopped and he responded well with antibiotics. A follow-up at 3 months post COVID-19 infection showed improvement of clinical symptoms with radiological resolution of ground glass changes. Conclusion: Corticosteroid inhaler should be cautioned in this case, in view of recent pneumonia and non-elevated serum eosinophil count. These groups of patients should be closely followed up to unmask interstitial lung disease that may present prior to COVID-19 and worsen post-infection. Optimizing pre-existing medical conditions should be the paramount intervention.

Development of bullous lung disease with pneumothorax following SARS-CoV-2 infection.

Cystic lung formation secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was described during coronavirus disease pandemic, but with relatively low prevalence. A rare yet under-recognized complication is that these cystic areas may progress to bullae, cavities and pneumothorax. We reported two cases of ruptured bullae with pneumothorax following SARS-CoV-2 infection. Two patients were discharged following SARS-CoV-2 pneumonia, which did not require invasive mechanical ventilation (IMV). However, both patients presented again a month later with shortness of breath. Repeated computed tomography (CT) thorax showed development of bullous lung disease and pneumothorax. The first patient underwent surgical intervention whilst the second patient was treated conservatively. Development of bullous lung disease following SARS-CoV-2 infection is rare but may be associated with serious morbidity. Patients whose general condition permits should be offered surgical intervention whilst conservative management is reserved for non-surgical candidates.