Spontaneous pneumomediastinum in a COVID-19 patient after renal transplantation: a case report and literature review (preprint)

ABSTRACT

Background: Spontaneous pneumomediastinum is a rare complication in COVID-19. Severe pneumonia complicated with pneumomediastinum after renal transplantation is rarely reported. Here we report a case of pneumomediastinum before invasive mechanical ventilation (IMV) in a COVID-19 patient with long-term immunosuppressive therapy after renal transplantation. Case presentation A 57-year-old man was admitted to our center with the main complaint of “fever and dyspnea for 5 days”. His past medical history was notable for renal transplantation and with long-term immunosuppressive and anti-rejection therapy. We made the diagnosis as COVID-19 pneumonia (severe type). We managed the patient with high flow nasal cannulae (HFNC), oral dexamethasone, broad-spectrum antibiotic, prophylactic anticoagulation, and anti-viral therapy with reduced dose of azvudine due to severe renal insufficiency. During hospitalization, the patient suffered from several times of aggravation of dyspnea. First bedside chest X-ray showed suspicious pneumomediastinum and subcutaneous emphysema, and the gas in the mediastinum gradually increased. The patient’s status deteriorated rapidly, we performed urgent trachea intubation and mechanical ventilation with low tidal volume lung-protective model and performed mediastinal decompression by suprasternal drainage. Despite our active rescue efforts, the patient still died of severe infection and multiple organ failure. Conclusions: In conclusion, we are the first to report spontaneous pneumomediastinum in a renal transplant recipient with severe COVID-19 pneumonia. This case reminds us that pneumomediastinum is a severe complication and a poor prognostic factor of COVID-19 pneumonia, especially when it occurred without positive pressure ventilation and in immunocompromised patients.