Air leaks, pneumatoceles, and air spaces in Covid-19 pneumon
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The recent report of SARS-CoV-2-related bilateral pneumothorax & covid-19-related bilateral pneumothorax appears to be a predictable consequence of the observation that SARS-CoV-2 pulmonary lesions have a predominantly peripheral and subpleural distribution, and may be associated with the presence of emphysema, cystic air spaces or cystic changes. All three terms are arguably synonymous with pneumatocele. Rupture of a pneumatocele, in turn, may be the trigger for occurrence of pneumothrax, pneumomediastinum, and pneumopericardium, respectively.

The size of covid-19-related pneumatoceles is also highly variable, with some falling into the category of giant bullae. Either in the context of multiple pneumatoceles or in the context of the isolated giant bulla, pneumothorax is an entirely predictable complication, which may be compounded by the occurrence of pneumomediastinum, not only when pneumothorax is bilateral, but also when it is unilateral.

Inspection of CT images of SARS-CoV-2, pneumonia should include a diligent search for even the minutest subpleural pneumatoceles so as to raise awareness of the risk of pneumothorax, pneumomediastinum & pneumopericardium. In a retrospective study of 78 consecutive patients with proven SARS-CoV-2-related pneumonia, cystic air space changes in 37.5% of subjects were documented. 10% of 81 symptomatic patients with Covid-19-related pneumonia had “cystic changes” identified on CT. Emphysema was documented in 5.3% of their 57 subjects with covid-19 pneumonia.

Even in an asymptomatic SARS-CoV-2 patient with minimal pulmonary involvement air leaks can still occur. Although no pneumatocele was identified at the time of presentation, it may well be that antecedent rupture of an unrecognised pneumatocele could have triggered the occurrence of pneumomediastinum.

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