Pulmonary emphysema, bullae, and pneumothorax in COVID-19 pneumonia

Critical Damage of Lung Parenchyma Complicated with Massive Pneumothorax in COVID-19 Pneumonia

It is already known that Coronavirus disease 2019 (COVID-19) may lead to various degrees and forms of lung parenchyma damage, but some cases take a strikingly severe course that is difficult to manage. We report the case of a 62-year old male, non-obese, non-smoker, and non-diabetic, who presented with fever, chills, and shortness of breath. The infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was diagnosed by real-time Polymerase Chain Reaction. Although the patient had been vaccinated with 2 doses of Pfizer-BioNTech COVID-19 vaccine 7 months earlier and had no risk factors for a severe outcome, serial computed tomography (CT) scan revealed lung involvement progressively extending from an initial 30% to 40% to almost 100% 2.5 months later. The spectrum of lung lesions included at first only ground-glass opacities and some tiny emphysema bullae, but later also bronchiectasis, pulmonary fibrosis, and large emphysema bullae as post-COVID-19 pulmonary sequelae. For fear of severe evolution of superimposed bacterial infection (Clostridoides difficile enterocolits and possibly bacterial pneumonia) the administration of corticosteroids was intermittent. Massive right pneumothorax secondary to bulla rupture, possibly favored by the indispensable high flow oxygen therapy, led to respiratory failure compounded by hemodynamic instability, and ultimately to the patient's final demise. COVID-19 pneumonia may cause severe lung parenchyma damage which requires long-term supplemental oxygen therapy. Beneficial or even lifesaving as it might be, high flow oxygen therapy may nonetheless have deleterious effects too, including the development of bullae that may rupture engendering pneumothorax. Corticosteroid treatment should probably be pursued despite superimposed bacterial infection to limit the viral induced damage to lung parenchyma.

Histopathological pulmonary findings of survivors and autopsy COVID-19 cases: A bi-center study

The coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), evolved into a global pandemic. As ACE2 on the surface of alveolar cells of the lung epithelium is one of the potential target receptors for SARS-CoV-2, the respiratory symptoms are the most common presentation of COVID-19. The aim of our study was to investigate the morphological findings in lung tissue after being infected by SARS-CoV-2 and compare histopathologic changes in patients with COVID-19 infection history who died to those who survived. We analyzed lung tissue samples from 9 patients who died from COVID-19 and from 35 patients with COVID-19 infection history who survived and had undergone lung surgery for different reasons. Most of histopathological changes in autopsy and survivors' cases overlapped; however, they occurred with different frequency. The predominant histologic finding both in the case of the deceased and the survivors was patchy distribution of foamy macrophages in the alveolar spaces. In comparison with autopsy cases viral cytopathic-like changes in hyperplastic pneumocytes were rarely observed in the survivors' lung tissue. Pulmonary edema, fibrin deposition within alveoli, bronchopneumonia, small vessel thrombosis and type II pneumocyte hyperplasia were also more often observed within autopsy cases. Life-threatening complications such as hyaline membrane formations and diffuse alveolar damage were present only within the deceased, whereas changes requiring enough time to progress to the fibrotic phase, such as organizing pneumonia, bronchiolization of the alveoli, and interstitial fibrosis were observed in the lung parenchyma only in survivors. Additionally, 14 cases of pulmonary pneumo-hematocele in patients with COVID-19 infection history who survived were observed. It is a newly observed entity in the form of a cystic lesion formed by large accumulation of blood and fibrin between the collapsed and rejected lung parenchyma and/or present with air-fluid levels. The thin wall of pneumo-hematocele is formed by the inter lobar interstitial fibroconnective tissue and has no epithelial lining or bronchial wall elements. As the COVID-19 pandemic continues, new complications following SARS-CoV-2 infection are identified. Newly observed entity in patients with COVID-19 infection history who survived is pulmonary pneumo-hematocele. The appearance of these lesion has become increasingly frequent.

Multiple Massive Bullae Formation Within Lung of SARS-CoV-2-Infected Patient

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has altered the world for more than two years and continues to impact the globe in numerous ways. This disease has a wide spectrum of presentations that can range from no symptoms at all to rapid decline and death. Complications of SARS-CoV-2 include acute respiratory failure, pneumonia, acute respiratory distress syndrome (ARDS), acute liver injury, acute cardiac injury, septic shock, blood clots, multisystem inflammatory syndrome in children, and chronic fatigue. Although many complications such as these and others exist, we are still seeing novel developments related to the virus. In this case report, we present a patient with SARS-CoV-2 who concurrently had a massive left lung bulla of unknown etiology. Due to the size and scale of this bulla, we suspect it to be a complication of his SARS-CoV-2 infection. A few cases have been described in the literature beforeand here we would like to contribute another one. Our goal is to help expand the body of evidence demonstrating the far-reaching and atypical nature that SARS-CoV-2 can present with today.

Post COVID-19 pneumo-hematocele: clinical presentation and treatment pathway

Objectives

The appearance of characteristic pulmonary lesions has been noted after COVID-19, being described as post-COVID-19 pneumo-hematocele. The aim of this study is to describe the clinical, histopathologic, and imaging features of pneumo-hematocele and to suggest a treatment algorithm for these patients.

Methods

A retrospective study was performed in patients admitted with a diagnosis of SARS-CoV2 infection from March 2020 to September 2021 who presented a pneumo-hematocele on imaging studies. Clinical and demographic variables were recorded, and CT scans were analyzed. A secondary analysis was performed to estimate the risk provided by the pneumo-hematocele diameter of developing pneumothorax.

Results

37 patients were diagnosed with pneumo-hematoceles, 97.3% were males with a median age of 41 ± 13 years and 51% were smokers. The mean diameter of the pneumatocele was 6.3 ± 2.8 cm; they were more common on the subpleural surface and in the inferior lobe. Thirty patients had ruptured pneumo-hematoceles and developed pneumothorax (81.1%); a total of 26 patients required surgery (70.3%). Lesions measuring 5 cm had a high risk of rupture (OR 6.8, CI 95% 1.1–42); those measuring 3 cm were prone to this complication. For each centimeter that the pneumo-hematocele diameter increases, the OR for rupture increases 1.5.

Conclusions

It appears that post-COVID-19 pneumo-hematocele occurs secondary to encapsulation of blood accumulation inside the lung, as a result of micro-capillary bleeding, with partial reabsorption of blood and subsequent air filling. We recommend surgery for patients with pneumo-hematoceles of 5 cm and those with persistent lesions of 3 cm.

Trial registration

Clinical Trial Registration: NCT05067881.

Case Report: Bullous Lung Disease Following COVID-19

More than 87% of patients report the persistence of at least one symptom after recovery from the Coronavirus disease 2019 (COVID-19). Dyspnea is one of the most frequently reported symptoms following severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) infection with persistent chest radiological abnormalities up to 3 months after symptom onset. These radiological abnormalities are variable and most commonly include ground-glass opacities, reticulations, mosaic attenuation, parenchymal bands, interlobular septal thickening, bronchiectasis, and fibrotic-like changes. However, in this case report, we describe findings of bullous lung disease as a complication of SARS CoV-2 infection. As the pandemic continues, there is a need to understand the multiple respiratory manifestations of post-acute sequelae of COVID-19. We, therefore, present this case to add to the current body of literature describing pulmonary disease as a consequence of SARS CoV-2 infection.

Post-Acute COVID-19 Syndrome for Anesthesiologists: A Narrative Review and a Pragmatic Approach to Clinical Care

Post-acute coronavirus disease 2019 (COVID-19) syndrome is a novel, poorly understood clinical entity with life-impacting ramifications. Patients with this syndrome, also known as "COVID-19 long-haulers," often present with nonspecific ailments involving more than one body system. The most common complaints include dyspnea, fatigue, brain fog, and chest pain. There currently is no single agreed-upon definition for post-acute COVID-19 syndrome, but most agree that criterion for this syndrome is the persistence of mental and physical health consequences after initial infection. Given the millions of acute infections in the United States over the course of the pandemic, perioperative providers will encounter these patients in clinical practice in growing numbers. Symptoms of the COVID-19 long-haulers should not be minimized, as these patients are at higher risk for postoperative respiratory complications and perioperative mortality for up to seven weeks after initial illness. Instead, a cautious multidisciplinary preoperative evaluation should be performed. Perioperative care should be viewed through the prism of best practices already in use, such as avoidance of benzodiazepines in patients with cognitive impairment and use of lung-protective ventilation. Recommendations especially relevant to the COVID-19 long-haulers include assessment of critical care myopathies and neuropathies to determine suitable neuromuscular blocking agents and reversal, preoperative workup of insidious cardiac or pulmonary pathologies in previously healthy patients, and, thorough medication review, particularly of anticoagulation regimens and chronic steroid use. In this article, the authors define the syndrome, synthesize the available scientific evidence, and make pragmatic suggestions regarding the perioperative clinical care of COVID-19 long-haulers.

A case of a patient with neurofibromatosis type I who developed pneumothorax and eosinophilic pleural effusion after suffering from COVID-19 pneumonia

Coronavirus disease 2019 (COVID-19) has become a global pandemic since its discovery in December 2019, and as the disease continues to evolve, varying complications associated with it continue to arise. In this regard, computed tomography has played an extremely important role in the diagnosis and evaluation of COVID-19 pneumonia and its complications. We encountered a case of a male patient with neurofibromatosis (type I) who developed concurrent pneumothorax and pleural effusion during his recovery period from severe COVID-19 pneumonia. Pulmonary fibrosis and emphysema were also confirmed. Furthermore, an eosinophil pleural effusion appeared and was prolonged during the healing process of COVID-19. This clinical presentation suggests that fibrosis and emphysema formation due to neurofibromatosis may have caused pneumothorax and pleural effusion.

Pneumothorax due to COVID-19: Analysis of case reports

Cases of pneumothorax/pneumomediastinum have been reported in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); however, the time to onset and hospital stay have rarely been studied. Coronavirus disease 2019 (COVID-19) patients with these complications are described to determine the time to onset, associated comorbidities, and location and duration of pneumothorax. A search in PubMed yielded simple frequencies and a bivariate analysis of deaths. There were 113 confirmed cases in 67 articles. The median time from the date of hospital admission to the presence of pneumothorax was 8 days. Right hemithorax was the most frequent form of pneumothorax. Almost half of the patients required intubation for invasive mechanical ventilation. Although the frequency of this phenomenon was not high among hospitalized patients with confirmed SARS-CoV-2, it was high among those who developed acute respiratory distress syndrome (ARDS). This study contributes to the literature because it presents a large number of patients who developed pneumothorax after admission, which was characterized by clinical deterioration (dyspnea, tachypnea, pleuritic chest pain, and subcutaneous emphysema) and low oxygen saturation levels. Pneumothorax/pneumomediastinum is recommended as a differential diagnosis, even without considering the presence of chronic pulmonary comorbidities or invasive mechanical ventilation.