Surgical management of a COVID-19-associated necrotic pneumo
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A 47-year-old man presented to hospital with symptoms typical of COVID-19 infection. Symptoms were ongoing for 2 days (fever, sweats, cough and shortness of breath). Nasopharyngeal swab confirmed the diagnosis of COVID-19. Chest X-ray (CXR) demonstrated right basal atelectasis. Inpatient duration was 3 weeks during which time 2 days of ventilatory support were required in the form of continuous positive airway pressure. Cardiovascular inotropic support was not required. The patient was treated with dexamethasone as part of the recovery trial and discharged after a 3-week period.

Two weeks following his original admission, he represented with chest pain and shortness of breath at which point his COVID-19 tests were negative. CT pulmonary angiogram (CTPA) showed a large left hydropneumothorax. Air fluid levels were seen in the collection which comprised the entirety of the left lower pleural cavity. The imaging did not clearly delineate between the left lower lobe/fluid collection and so the differential between parenchymal abscess, necrotic lung and empyema was unclear.

The right lung demonstrated patchy basal consolidation and a small air fluid collection consistent with COVID-19 infection. Empirical antimicrobial therapy in the form of clarithromycin and piperacillin/tazobactam was commenced at the referring hospital. Antibiotics were escalated to meropenem on transfer to the regional thoracic centre. An intercostal drain was inserted with an anterior approach, using Seldinger principles. Pleural fluid sampling demonstrated a pH of 7.1 indicative of infection. Microbiology cultures were reported negative but the patient was on broad spectrum antibiotics prior to sampling. However, this intervention failed to drain the pleural cavity.

Imaging failed to differentiate between empyema, parenchymal abscess and necrotic lung. As such, lytic therapy was not considered. The patient underwent a left uniportal video-assisted thoracoscopy 6 weeks after his initial presentation with the intent of performing a left pleural washout and decortication. However, on visualisation of the lung it became apparent that pathology was primarily intraparenchymal rather than pleural. The lower lobe was dark in colour, friable and clearly necrotic. The surgical team proceeded to left lower lobectomy.

The patient returned to the ward where antibiotics were continued. An immediate fall in white cell count and C reactive protein was noted with continued decline toward normal. Sinus tachycardia persisted for 2 weeks but was resolved by the time of discharge. No further surgical intervention was required following return to baseline physical function. Antibiotics were discontinued at the point of discharge. The patient was mobile and independent in activities of daily living. There was no subsequent readmission. CXR at the time of discharge demonstrated clear pleural spaces with loss of volume in the left hemithorax consistent with his post lobectomy status.