Pneumothorax and pneumomediastinum in COVID-19: A case series.

COVID- 19 has become a major pandemic affecting more than 11 million people worldwide. Common radiological manifestations of COVID-19 include peripheral based ground-glass or consolidative opacities; however, pneumothorax and pneumo-mediastinum are very rare manifestations; even more so within patients not on mechanical ventilation. We present a case series of 5 patients with COVID-19 who either presented with or developed spontaneous pneumothorax or pneumo-mediastinum within the course of hospitalization. With the exception of one patient, all other patients developed pneumothorax as a late manifestation in their illness; more than 10 days after initial symptom onset in COVID-19. From within this case series, all patients who developed spontaneous pneumothorax or pneumo-mediastinum during hospitalization subsequently succumbed to the illness. Spontaneous pneumothorax or pneumo-mediastinum may be an important late manifestation in COVID-19; even in spontaneously breathing patients. This may be related to development of cystic changes within the lung parenchyma. Although the clinical relevance of this finding is unknown; in our series, it portended a worse prognosis in the majority of patients.

COVID-19 and Blood Clots: A Report of Massive Pulmonary Embolism in COVID-19 Patient Supported on Veno-Venous ECMO and the Utility of Thrombolysis.

COVID-19 morbidity and mortality are not equivalent to other etiologies of acute respiratory distress syndrome (ARDS) as fulminant activation of coagulation can occur, thereby resulting in widespread microvascular thrombosis and consumption of coagulation factors. A 53-year-old female presented to an emergency center on two occasions with progressive gastrointestinal and respiratory symptoms. She was diagnosed with COVID-19 pneumonia and admitted to a satellite intensive care unit with hypoxemic respiratory failure. She was intubated and mechanically ventilated, but her ARDS progressed over the next 48 hours. The patient was emergently cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO) and transferred to our hospital. She was in profound shock requiring multiple vasopressors for hemodynamic support with worsening clinical status on arrival. On bedside echocardiography, she was found to have a massive pulmonary embolism with clot-in-transit visualized in the right atrium and right ventricular outflow tract. After a multidisciplinary discussion, systemic thrombolytic therapy was administered. The patient's hemodynamics improved and vasopressors were discontinued. This case illustrates the utility of bedside echocardiography in shock determination, the need for continued vigilance in the systematic evaluation of unstable patients in the intensive care unit, and the use of systemic thrombolytics during V-V ECMO in a novel disease process with evolving understanding.

Bilateral spontaneous pneumothoraces in anaplastic thyroid cancer.

Spontaneous pneumothorax is rarely associated with cancer. We describe a 73 year old man who presented with recurrent tumor in the right neck, mediastinal lymphadenopathy and bilateral pulmonary nodules after thyroidectomy. He was treated with lenvatinib and presented with bilateral pneumothoraces. Anaplastic thyroid cancer is an aggressive subtype of thyroid cancer that has limited response to cytotoxic chemotherapy and poor prognosis. Recent reports show that targeted therapy with a multiple receptor tyrosine kinase inhibitor, lenvatinib, may have improvement in progression-free survival, but rarely pneumothorax has been reported in those with lung metastases. Various mechanisms have been postulated, but necrosis of pulmonary lesions and/or subpleural micrometastases leading to bilateral pleural defects likely resulted in the development of pneumothoraces for our patient.

Sensitivity of Initial Thoracentesis for Malignant Pleural Effusion Stratified by Tumor Type in Patients with Strong Evidence of Metastatic Disease.

BACKGROUND: Thoracentesis with cytological examination of pleural fluid is the initial test of choice for evaluation of pleural effusions in patients with suspected malignant pleural effusion (MPE). There is limited data on the sensitivity of thoracentesis stratified by tumor type. A better understanding of stratified sensitivities is of clinical interest, and may guide early and appropriate referral for pleural biopsy. OBJECTIVE: The primary objective was sensitivity of thoracentesis with pleural fluid cytology stratified by tumor type. METHODS: This is a retrospective cohort study of consecutive patients with a solid tumor malignancy with proven or strong suspicion for metastatic disease with new pleural effusions that underwent an initial thoracentesis. Only patients with metastatic disease were included. RESULTS: Of the 725 patients examined, 63% had pleural fluid cytology positive for malignancy. Sensitivity of thoracentesis varied from a low of 0.38 (95% CI 0.13-0.68) in head and neck malignancy, 0.38 (95% CI 0.15-0.65) in sarcoma, and 0.53 (95% CI 0.34-0.72) in renal cancer to a high of 93 (95% CI 88-97) in breast cancer, and 100 (95% CI 0.82-100) in pancreatic cancer. Factors associated with an increased risk of MPE included larger amount of fluid drained (p = 0.014) and higher pleural fluid protein (p = 0.002). The only factor associated with decreased risk of MPE if first cytology was negative for malignancy was the presence of contralateral effusion (p = 0.005). CONCLUSIONS: Sensitivity of thoracentesis for solid tumors varies significantly depending on the type of tumor and is lowest in those with sarcomas, head and neck malignancies, and renal cell cancers.

A 64-Year-Old Woman With an Incidental Pulmonary Nodule.

CASE PRESENTATION: A 64-year-old Latin American woman was referred for evaluation of an incidental pulmonary nodule. She had originally presented to her primary care physician with complaints of abdominal pain warranting a CT scan of the abdomen, which revealed a right lower lobe pulmonary nodule. She denied any complaints of shortness of breath or cough. Review of systems was unremarkable and medical history was significant for hypertension only. She also denied primary or secondary tobacco exposure or any recreational drug abuse. Patient denied any recent travels and resided in Houston, Texas. There was no family history of malignancy or lung disease.