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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 129-132

Combined spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema in a coronavirus disease-2019 pneumonia patient with previously healthy lungs


1 Department of Medical Education, HMC, Doha, Qatar
2 Department of Internal Medicine, HMC, Doha, Qatar

Date of Submission19-Jul-2020
Date of Acceptance10-Aug-2020
Date of Web Publication21-Sep-2020

Correspondence Address:
Prof. Elmukhtar Habas
Department of Internal Medicine, HMC, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_63_20

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  Abstract 


Breathlessness was the common presenting symptom, but combined spontaneous–pneumothorax–pneumomediastinum–subcutaneous emphysema (SPPSE) is not known complication of coronavirus disease-2019 (COVID-19) pneumonia. We are report a case of CSPPSE in a male adult with previously healthy lungs infected with COVID-19 pneumonia. On May 16, 2020, he was presented to the Emergency Department of Hamad General Hospital, complaining of fever, leukocytosis, and normal CRP. Chest X-ray showed mild COVID-19-related pneumonia. He was started on the local Qatari-recommended protocol for COVIMD-19. Suddenly, his oxygen saturation was deteriorated and transferred to the medical intensive care unit where he had noninvasive ventilation. Chest X-ray showed right pneumothorax, but there was no evidence of pneumomediastinum or subcutaneous emphysema. On May 30, chest computed tomography was conducted and did not show any evidence of chronic lung diseases that can produce CSPPSE. Finally, on June 13, the patient was labeled as recovered COVID-19 patient. CSPPSE is a complication of COVID-19 pneumonia, even in previously normal lungs.

Keywords: Coronavirus disease-2019, pneumomediastinum, pneumothorax, spontaneous, subcutaneous emphysema, viral pneumonia


How to cite this article:
Abbood T, Habas E. Combined spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema in a coronavirus disease-2019 pneumonia patient with previously healthy lungs. Libyan J Med Sci 2020;4:129-32

How to cite this URL:
Abbood T, Habas E. Combined spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema in a coronavirus disease-2019 pneumonia patient with previously healthy lungs. Libyan J Med Sci [serial online] 2020 [cited 2020 Oct 24];4:129-32. Available from: https://www.ljmsonline.com/text.asp?2020/4/3/129/295619




  Introduction Top


In December 2019, in Wuhan, Hubei Province, China, severe acute respiratory syndrome coronavirus 2 pandemic occurred and was officially declared as a global health emergency by the World Health Organization on January 30, 2020.[1],[2],[3] Coronavirus disease-2019 (COVID-19) causes severe viral pneumonia that is typically characterized by bilateral, multilobar ground-glass like opacities and consolidations exclusively at the lungs periphery in the chest radiography and by computed tomography (CT) scan.[4],[5],[6],[7] In addition to the common presenting symptoms of dry cough, fever, myalgia, fatigue, and breathlessness, there were other serious complications that were reported such as acute respiratory distress syndrome (ARDS), acute kidney or cardiac injury, secondary infection, and liver dysfunction.[8] Acute-onset breathlessness is not uncommon symptom in COVID-19 pneumonia, but other causes such as acute pulmonary edema and acute pulmonary embolism are not uncommon. Pneumothorax is a known complication in chronic obstructive lung diseases, especially emphysema, post-tuberculosis, and lung abscess rapture but up to the current limited knowledge about this unique virus; the appearance of combined spontaneous–pneumothorax–pneumomediastinum–subcutaneous emphysema (SPPSE) in previously healthy lungs following COVID-19 pneumonia was not noted during the virus pandemic. Therefore, we report a case of a COVID-19 pneumonia complicated by combined SPPSE in previously healthy lungs.


  Case Report Top


On May 16, 2020, a 55-year-old male nonsmoker patient was presented to the Emergency Department of Hamad General Hospital with a history of fever, shortness of breath, cough, and throat irritation of 8-day duration. There was no history of chest pain or other related significant complaints. He contacted asymptomatic COVID-infected person few days prior to his symptoms. The patient has well-controlled diabetic for 2 years on oral medications. On examination, the patient was not tachypneic or cyanotic, and the pulse rate was 80 beats/min and the respiratory rate was 18/min. The chest and cardiovascular examination was unremarkable. WBC count was mildly elevated (11.2 × 103/μL), but there were normal C-reactive protein (2.7 mg/L), D-dimer (0.39 mg/L), and serum ferritin (92.4 mcg/L). Nasopharyngeal swab was positive for COVID-19 using reverse transcription–polymerase chain reaction (PCR). Chest X-ray at presentation showed subtle infiltrates in the left lung lower lobe [Figure 1]a.
Figure 1: (a) At presentation right lung base infiltrate. (b) At presentation right lung base infiltrate. (c) Right pneumothorax (i), Pneumomediastinum (II), Subcutaneous emphysema (II). (d) Subcutaneous emphysema (i), Pneumomediastinum (II). (e) At day before discharge

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Hospital course

He had all isolation measures that were started on the local-approved treatment protocol for COVID-19 pneumonia as following: azithromycin (500 mg BID for 7 days), hydroxychloroquine (400 mg BID first day then 400 mg daily for 9 days), and amoxicillin/clavulanic acid (625 mg TID for 7 days). On May 21, the patient suddenly deteriorated, had 32/min respiratory rate, and oxygen saturation dropped. Ten liters of oxygen flow was needed via the nonrebreathing mask. Despite that, his oxygen saturation was hardly maintained at 97%. By this time, he was transferred to the medical intensive care unit and was labeled as severe COVID-19-related pneumonia, and methylprednisolone 40 mg daily was started. He was kept on CPAP, FIO240, and without any intubation attempt. Repeated plain portal chest X-ray showed a significant change in the bilateral lower lung zones with scattered ground-glass opacities [Figure 1]b in comparison to the prior chest X-ray dated May 19, 2020.

On May 22, the patient improved, and his oxygen requirement decreased gradually to 2 liters by nasal cannula and was given incentive spirometry. Nevertheless, on May 26, dramatic quick deterioration happened. The patient had severe sudden shortness of breath and oxygen saturation abruptly dropped to 70%. Rapid response team was activated, chest X-Ray was done and it showed moderate-to-severe right-sided pneumothorax, right lung collapse, pneumomediastinum at the left side of the main trachea. There was also bilateral neck, and chest anterior wall subcutaneous emphysema, and new patchy infiltrates were noted in the left lower lung zone [Figure 1]c. On May 27, the right-sided thoracic tube was inserted and right lung expanded, but subcutaneous emphysema was still seen. On May 28, a repeated chest X-ray showed more bilateral lower zone pneumonia infiltration that was more prominent in the left lung, with ill-defined left hemidiaphragm and obliteration of cardiophrenic angle. There was an evidence of mild bilateral residual subcutaneous emphysema [Figure 1]d. On May 30, the chest tube was removed, and chest X-ray did not show any evidence of pneumothorax recurrence [Figure 1]e. There was a good improvement of the lungs' infiltration, and the subcutaneous emphysema was resolved completely. Chest CT was done to find out any precipitating cause of pneumothorax. It revealed bilateral multifocal confluent airspace consolidations, with peripheral predominance in the upper lobes. Multifocal areas of ground-glass infiltrates were seen interspersing at both upper lobes and middle lobe with an interlobular septal thickening. The trachea was central and looked normal, and there were no emphysematous bullae or emphysematous cystic changes within the lung fields. Surprisingly, there were multiple foci of air in the mediastinum, behind the sternum, around the pericardium, and around the wall of the esophageal distal part, and thin crescent like of air (8 mm thick) was seen medial to the left lung adjoining the anterior mediastinum [Figure 2]a and b]. A minimal left pneumothorax and remnant of right-side pneumothorax were reported. After 5 days, the patient was clinically stable on room air with almost 100% oxygen saturation. On the June 8, nasal and throat swab PCR was reported negative for COVID-19. The patient was declared as cured COVID-19 patient. On June0, repeated chest X-ray showed much improvement without any evidence of air leaked and finally discharged home on the of June 13.
Figure 2: (a) Computed tomography minimal left pneumothorax. (b) Computed tomography minimal pneumopericardium (I) and bilateral basal infiltrate (II)

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  Discussion Top


The high CT sensitivity and wide availability made chest CT an essential screening tool for COVID-19 pulmonary complications. Other investigations such as PCR testing and plain X-ray of chest abilities are limited in predicting early lung changes. Specific CT findings of pulmonary ground-glass infiltrates and consolidations that are usually bilateral and are distributed at the dorsal and subpleural lungs regions are common findings in COVID-19 pneumonia. Chest CT has an essential role in the management and follow-up of COVID-19 patients because it allows COVID-19 pulmonary disease course evaluation and essentially helps in acute pulmonary COVID-19 complication detection such as pulmonary embolism and pneumothorax detection[9],[10],[11] and follow-up thereafter. To date, spontaneous pneumothorax has been seldomly reported in COVID-19 patients, and up to the best of our knowledge, this is the first reported case of CPPSE in COVID-19-infected patient.

Rubin et al. from Wuhan reported that subpleural bullae that were detected by chest CT might be the possible cause of mediastinal emphysema and pneumothorax.[10] Our patient, however, had no any radiological evidence of pulmonary cyst or bullae in the chest CT scan after full lung expansion, and the chest-X-ray at presentation did not show any evidence of lung emphysema or underling long-term diseases that may cause an air leak. Larger studies reported that pneumothorax occurred in 1%–2% of adults COVID-19 patients,[5],[8],[9],[12],[13],[14] yet our case has a new, unexpected complication of COVID-19 virus infection.

Spontaneous pneumothorax is a known complication in ARDS which occurs mostly due to pressure and volume-related alveolar rupture.[15] As lung tissue histology of COVID-19 pneumonia patients revealed that desquamation of pneumocytes and hyaline membrane formation occurs in ARDS.[8] Before the onset of severe dyspnea, our patient suffered from coughing, which increases alveolar pressure. The patient has not any known precipitating cause of air leak from the lungs such as chronic lung diseases, long thin body built (173 cm/74 kg, respectively). He was not a smoker, and the patient had no traumatic interventions as endotracheal intubation and any positive pressure ventilation procedure that might cause combined SPPSE. This had made us confident to report a COVID-19 pneumonia with this type of combined lesions, to draw attention, and to increase the awareness to SPPSE as a complication of this new emerging infection.


  Conclusion Top


Combined SPPSE needs to be considered when COVID-19 pneumonia patient deteriorates. Chest CT scan has a powerful diagnostic yield in these types of patients. Further larger studies are urged to evaluate this complication during this COVID-19 pandemic.

Acknowledgments

We thank the patient for granting us permission to publish this information.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
    
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Omrani SA, Cornoavirus disease 2019: The story so far. LJMS 2020;4:52-7.  Back to cited text no. 3
    
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Wu J, Wu X, Zeng W, Guo D, Fang Z, Chen L, et al. Chest CT findings in patients with coronavirus disease 2019 and its relationship with clinical features. Invest Radiol 2020;55:257-61.  Back to cited text no. 4
    
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Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID-19): A systematic review of imaging findings in 919 patients. AJR Am J Roentgenol 2020;215: 87-93.  Back to cited text no. 5
    
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Ye G, Pan Z, Pan Y, Deng Q, Chen L, Li J, et al. Clinical characteristics of severe acute respiratory syndrome coronavirus 2 reactivation. J Infect 2020;80:14-17.  Back to cited text no. 6
    
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Cheng ZJ, Shan J. 2019 Novel coronavirus: Where we are and what we know. Infection 2020;48:155-63.  Back to cited text no. 7
    
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Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course andoutcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8: 475-481.  Back to cited text no. 8
    
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Pan Y, Guan H, Zhou S, Wang Y, Li Q, Zhu T, et al. Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): A study of 63 patients in Wuhan. China Eur Radiol 2020;30:3306-3309.  Back to cited text no. 9
    
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Rubin GD, Ryerson CJ, Haramati LB, Sverzellati N, Kanne JP, Raoof S, et al. The Role of chest imaging in patient management during the COVID-19 pandemic: A multinational consensus statement from the fleischner society. Radiolo 2020;158:106-116.  Back to cited text no. 10
    
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Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N,et al. Chest CT findings in coronavirus disease-19 (COVID-19):Relationship to duration of infection. Radiolo 2020;295:202-207.  Back to cited text no. 11
    
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Flower L, Carter JL, Rosales Lopez J, Henry AM. Tension pneumothorax in a patient with COVID-19. BMJ Case Rep 2020:1-4.  Back to cited text no. 12
    
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Sun R, Liu H, Wang X. Mediastinal Emphysema, Giant Bulla, and pneumothorax developed during the course of COVID-19 pneumonia. Korean J Radiol 2020;21:541-4.  Back to cited text no. 13
    
14.
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 14
    
15.
Woodside KJ, vanSonnenberg E, Chon KS, Loran DB, Tocino IM, Zwischenberger JB. Pneumothorax in patients with acute respiratory distress syndrome: Pathophysiology, detection, and treatment. J Intensive Care Med 2003;18:9-20.  Back to cited text no. 15
    


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