Spontaneous pneumomediastinum in post-COVID syndrome

ABSTRACT

Learning Objective Pneumomediastinum possible sequelae of post-COVID presentation with minor COVID infection Case presentation A 42-year male with Covid-19 pneumonia presented following an episode of presyncope with associated severe weakness and hemoptysis. The patient had Covid-19 pneumonia two months earlier and needed no hospitalization. At this presentation, he tested negative for Covid-19, with a 30-pound diet-related weight loss, brain fog, occasional shortness of breath, and night sweats since his infection. Respiratory rate 23/minute, occasional wheezing. Besides normal hemoglobin, WBC 12.7 with elevated ANC, normal electrolytes except slightly elevated chloride, D-Dimer of 0.85, ferritin of 907.8, CRP of 19.6, normal BNP, and normal troponin. Chest CTA demonstrated ground-glass opacities, small anterior pneumothoraxes, and moderate pneumomediastinum with a cystic lesion in the right upper lobe that may reflect a pneumatocele. Head CT and EKG were unrevealing. He was managed conservatively with breathing treatments and cough suppressants. The patient complained of neck pain the next day, and a repeat chest x-ray revealed subcutaneous emphysema in the neck area. Despite this, the patient had no further clinical manifestations during his hospital stay with stable pneumomediastinum and pneumothorax on follow-up chest x-rays with a reduction in subcutaneous neck emphysema. He denied repeat episodes of hemoptysis or presyncope and was subsequently discharged three days after admission with a followup chest x-ray in two weeks. Discussion Post-Covid complications including cough, dyspnea, and pulmonary fibrosis may contribute to alveolar barotrauma and subsequent pneumomediastinum, which may contribute to serious complications, including cardiac tamponade. Pneumatoceles are air-filled cavitary lesions usually seen post-infection, trauma, or more extensive cystic disease of the lung. The evolution happens post pneumonia, inflammation, and narrowing of the bronchus leads to the formation of an endobronchial ball valve, leading to the distal dilatation of bronchi and alveolar space. The obstruction is thought to be caused by inflammatory exudates in the airway lumen, permitting air to enter the cystic space but not to leave it. Subsequent enlargement of the pneumatocele occurs either due to pressure from the adjacent pneumatocele or intraluminal inflammatory exudates. 2 This case demonstrates the need to consider pneumomediastinum as a complication even in non-serious Covid infections with no acute hypoxic respiratory failure presentation. Conclusion Many case reports have detailed spontaneous pneumomediastinum in patients with active Covid-19 pneumonia, especially in intubated patients. Few publications have linked pneumomediastinum to post-Covid pneumonia. Pneumomediastinum should be an important consideration in patients with active Covid-19 and those who have recovered from even minor infection.