Exuberant spontaneous pneumothorax, pneumomediastinum, pneum
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A 54-year-old man diagnosed with COVID-19 was admitted to the emergency department for increasing shortness of breath following a 2-week history of fever and fatigue. At admission, his chest X-ray showed bilateral patchy infiltrates, he was hypoxemic and noninvasive mechanical was initiated. On hospital day 4, subcutaneous emphysema was noticed and chest CT showed subcutaneous emphysema extending from the cervical region along the arms associated with pneumomediastinum, pneumopericardium and bilateral pneumothorax.

A chest drain was placed with pneumothorax resolution. However, respiratory failure further deteriorated and invasive mechanical ventilation was started on the next day. The patient was admitted to the intensive care unit (ICU). Due to prolonged ventilation and critical illness myopathy, a tracheostomy was performed after 22 days of invasive ventilation.

On hospital day 25, a right-sided hypertensive pneumothorax requiring decompression complicated the disease course. CT scan revealed a septate hydropneumothorax suggestive of empyema and a pneumatocele on the same side. After insertion of another chest drain directed at the septate collection and a course of antibiotics, the patient progressively improved. Repeated CT scan showed a reduction in the size of the hydropneumothorax. After 54 days in the ICU, the patient was transferred to the ward.

Pneumothorax has been reported as a complication occurring during the course of COVID-19 pneumonia in about 1% of hospital admissions and 2% of ICU admissions. Likewise, cases of pneumomediastinum and subcutaneous emphysema have been described in the literature occurring at presentation or during disease course.

Traditional risk factors for pneumothorax and mediastinal emphysema include tall and thin stature, smoking, chronic lung disease or asthma. However, an association between these features and pneumothorax occurring in patients with COVID-19 has not been established and it seems that the particular pathophysiology of SARS-CoV-2 pneumonia might have a role in such complications. Despite the mechanism remaining unknown, it is speculated that increased alveolar pressure and diffuse alveolar injury make alveoli prone to rupture, then causing air dissection into the mediastinum and subcutaneous tissue.

Source: https://casereports.bmj.com/content/14/5/e243861?rss=1
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