Massive emphysema subcutis, pneumothorax, pneumomediastinum and pneumoperitoneum as uncommon complication of covid-19 pneumonia, a rare case

COVID-19: A Possible Cause of Spontaneous Pneumoperitoneum

Introduction

Pneumoperitoneum is the presence of air within the peritoneal cavity and is mostly caused by organ rupture. Spontaneous pneumoperitoneum accounts 5% to 15% of the cases and occurs in the absence of organ damage. The pulmonary origin of pneumoperitoneum is unusual, and probably associated with mechanical ventilation and alveolar leak. In patients with coronavirus disease 2019 (COVID-19) there are some reports of air leak, like pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema.

Case presentation

We present the case of a 70-year-old man with COVID-19 pneumonia admitted to the Intensive Care Unit (ICU). Since admission he was on Non-Invasive Ventilation (NIV), without improvement, needing Invasive Mechanical Ventilation (IMV) due to severe respiratory failure. Five days after IMV despite protective lung ventilation, massive spontaneous subcutaneous emphysema, pneumomediastinum and pneumoperitoneum were diagnosed. Besides initial conservative management 12 hours later, the patient developed abdominal compartment syndrome requiring percutaneous needle decompression.

Conclusions

Pneumoperitoneum can be considered a rare complication of COVID-19 pneumonia and its management, resulting not only from the viral pulmonary but also from secondary causes. Conservative management should be usually enough. However, in the presence of abdominal compartment syndrome prompt recognition and treatment are crucial and eventually lifesaving.

Pneumomediastinum and Subcutaneous Emphysema in an Adult Male From Nepal Infected With COVID-19

Pneumomediastinum and subcutaneous emphysema have been reported in COVID-19 around the world except for Nepal. We report a case of a 44-year-old male infected with COVID-19 who developed pneumomediastinum and subcutaneous emphysema during his eighth day of intubation at the hospital. He was managed with remdesivir, antibiotics, mechanical ventilation, steroid, and heparin following which he recovered well. Barotrauma-related complications are common in COVID-19 and our case highlights the importance of conservative management for such complications and the rarity of such conditions in Nepal.

Spontaneous pneumomediastinum and COVID-19 pneumonia: Report of three cases with emphasis on CT imaging

Spontaneous pneumomediastinum is a rare complication of coronavirus disease 2019. The published literature consists mainly of case reports and small case series. There are still many questions regarding the pathogenesis, the prognostic significance and the implications on patient management. In our hospital, 3 coronavirus disease 2019 patients developed spontaneous pneumomediastinum: 1 on admission at the emergency department and the other 2 during hospitalization. In this study we describe their clinical course and computed tomography (CT) findings. All of them had severe disease according to the total severity score on admission CT. The management of pneumomediastinum was conservative and follow-up CT showed resolution in all patients. As the correlation between extension of parenchymal lung lesions and development of pneumomediastinum is still under investigation, we highlight the importance of reporting the severity score on chest CT in order to obtain more comparable results between different studies. Furthermore, in this tragic circumstance we also had the opportunity to familiarize ourselves with the otherwise uncommon occurrence of air along the bronchovascular sheaths (Macklin effect) and evaluate the ability of CT to detect it.