Pneumothorax in a COVID-19 Pneumonia Patient without Underlying Risk Factors

Recurrent spontaneous pneumothorax secondary to lung cystic lesions in a case of convalescent COVID-19: a case report and literature review

BACKGROUND

While spontaneous pneumothorax has been documented in COVID-19 patients, reports on recurrent spontaneous pneumothorax due to cystic lesions in convalescent COVID-19 patients are scarce. The progression of these lung cystic lesions remains inadequately explored.

CASE PRESENTATION AND LITERATURE REVIEW

An 81-year-old male, a non-smoker with a history of rheumatoid arthritis, presented with fever, cough, and expectoration for 14 days. Initially diagnosed with moderate COVID-19, he deteriorated to severe COVID-19 despite adherence to local treatment guidelines. Successive identification of three cystic lesions termed "bulla" or "pneumatocele", and one cystic lesion with air-fluid level, referred to as "pneumo-hamatocele" (PHC), occurred in his lungs. Gradual improvement followed anti-inflammatory therapy and optimal supportive care. However, on day 42, sudden worsening dyspnea prompted a computed tomography (CT) scan, confirming a right spontaneous pneumothorax and subcutaneous emphysema, likely due to PHC rupture. Discharge followed chest tube implementation for pneumothorax resolution. On day 116, he returned to the hospital with mild exertional dyspnea. Chest CT revealed recurrent right pneumothorax from a remaining cyst in the right lung. Apart from our patient, literature retrieval identified 22 COVID-19 patients with spontaneous pneumothorax due to cystic lesions, with a male predominance (95.6%; 22/23). Diagnosis of pneumothorax and lung cystic lesions occurred around day 29.5 (range: 18-35) and day 26.4 (± 9.8) since symptom onset, respectively. Except for one patient whose pneumothorax occurred on day seven of illness, all patients eventually recovered.

CONCLUSIONS

Recurrent spontaneous pneumothorax secondary to lung cystic lesions may manifest in convalescent COVID-19 patients, particularly males with COVID-19 pneumonia. Chest CT around 2 to 3 weeks post-symptom onset may be prudent to detect cystic lesion development and anticipate spontaneous pneumothorax.

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.

Bilateral refractory pneumothorax treated by pleurodesis and bronchial occlusion in a COVID-19 patient

Coronavirus disease 2019 (COVID-19) has become a worldwide outbreak, and it can cause various symptoms and complications. However, pneumothorax secondary to COVID-19 is relatively uncommon. We herein report a 60-year-old man with bilateral refractory pneumothorax with severe COVID-19. In patients with poor general health and who are difficult to undergo surgery for pneumothorax post-COVID-19, internal treatments such as chest drainage, bronchial occlusion, and pleurodesis are essential to relieving refractory pneumothorax. It also indicates that autologous blood patch pleurodesis is a useful method in terms of efficacy and side effects.

Prognosis of Spontaneous Pneumothorax/Pneumomediastinum in Coronavirus Disease 2019: The CoBiF Score

Objectives: Pneumothorax and pneumomediastinum are associated with high mortality in invasively ventilated coronavirus disease 2019 (COVID-19) patients; however, the mortality rates among non-intubated patients remain unknown. We aimed to analyze the clinical features of COVID-19-associated pneumothorax/pneumomediastinum in non-intubated patients and identify risk factors for mortality. Methods: We searched PubMed Scopus and Embase from January 2020 to December 2021. We performed a pooled analysis of 151 patients with no invasive mechanical ventilation history from 17 case series and 87 case reports. Subsequently, we developed a novel scoring system to predict in-hospital mortality; the system was further validated in multinational cohorts from ten countries (n = 133). Results: Clinical scenarios included pneumothorax/pneumomediastinum at presentation (n = 68), pneumothorax/pneumomediastinum onset during hospitalization (n = 65), and pneumothorax/pneumomediastinum development after recent COVID-19 treatment (n = 18). Significant differences were not observed in clinical outcomes between patients with pneumomediastinum and pneumothorax (±pneumomediastinum). The overall mortality rate of pneumothorax/pneumomediastinum was 23.2%. Risk factor analysis revealed that comorbidities bilateral pneumothorax and fever at pneumothorax/pneumomediastinum presentation were predictors for mortality. In the new scoring system, i.e., the CoBiF system, the area under the curve which was used to assess the predictability of mortality was 0.887. External validation results were also promising (area under the curve: 0.709). Conclusions: The presence of comorbidity bilateral pneumothorax and fever on presentation are significantly associated with poor prognosis in COVID-19 patients with spontaneous pneumothorax/pneumomediastinum. The CoBiF score can predict mortality in clinical settings as well as simplify the identification and appropriate management of patients at high risk.

Spontaneous Loculated Bilateral Hydropneumothoraces in a Patient with Recent COVID-19 Infection

A 53-year-old male presented to the emergency room with chest pain, shortness of breath, and back pain. He had recently recovered from COVID-19 infection and returned home on room air. Chest imaging showed bilateral hydropneumothoraces that were not present on the imaging performed during his prior admission three weeks ago. The patient was treated with bilateral chest tube drainage and oxygen support and responded well to treatment. This case represents a unique occurrence of spontaneous loculated bilateral hydropneumothoraces in the context of recent clinical recovery from COVID-19 infection requiring inpatient treatment. This case highlights the importance of an awareness of a potential sequela of COVID-19 that may occur even after presumed clinical recovery.

Spontaneous Pneumothorax as a Late Complication of Mild COVID-19 Infection: A Case Report

Spontaneous pneumothorax (PTX) is a rare but life-threatening complication of lung injuries sustained from severe COVID-19 infection, most commonly associated with mechanical ventilation. Development of spontaneous PTX in patients after only mild COVID-19 infections not requiring hospitalization is even rarer. Here, we present the case of a 37-year-old male with spontaneous PTX secondary to a mild COVID-19 infection diagnosed one-month prior. A computed tomography (CT) scan of the chest revealed new air-filled cysts thought to be mediated by the inflammatory response to his acute infection, and his PTX was thought to be secondary to cyst wall rupture due to prolonged coughing. He was successfully treated with a chest tube and supplemental oxygen and, at a two-month follow-up, demonstrated clinical and radiographic improvement.

Pneumothorax in otherwise healthy non-intubated patients suffering from COVID-19 pneumonia: a systematic review

Background

Cases of spontaneous pneumothorax have been described in patients suffering from coronavirus disease 2019 (COVID-19) pneumonia. The aim of this study is to systematically review all the cases of spontaneous pneumothorax that occurred in healthy patients with no underlying lung disease and who did not receive invasive mechanical ventilation.

Methods

A PubMed research was conducted. The following data were collected: age, sex, side of the pneumothorax, smoking habit, time form onset of symptoms to the diagnosis of pneumothorax, the development of new bullous lesions on computed tomography and the type of treatment. In order to analyze the most homogeneous population possible, intubated patients were deliberately excluded. In total, 44 cases of spontaneous pneumothorax in otherwise healthy patients were taken into account. Since the available data were extracted from small observational studies, no particular bias risk assessment was performed. Descriptive statistics were used to synthesize results.

Results

There were 37 male (84.1%) and 6 female (13.6%) patients. The majority of patients (66%) were treated only by chest tube thoracostomy, which most of the times resulted in a complete resolution of the pneumothorax. Simple surveillance was applied in 10 cases. Three patients underwent minimally invasive surgery. In 14 cases (31.8%) air-filled lesions were detected on imaging. Eleven patients received corticosteroids during their hospital stay. In the majority of cases (86.3%) the pneumothorax was resolved.

Discussion

Even if the level of evidence, derived from case reports and small case series is low, the existence of a true secondary spontaneous pneumothorax due to SARS-CoV-2 should be recognized. Imaging techniques should be repeated throughout the clinical course of the patients in order to detect newly developed pulmonary complications. Surgical treatment is feasible and patients whose general condition permits, should be offered surgery according to the existing guidelines regarding spontaneous pneumothorax. National registries and databases are necessary in order to better understand the pathogenesis and complications of this novel entity.

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.

Secondary Spontaneous Pneumothorax in a COVID-19 Recovered Patient

Coronavirus disease 2019 (COVID-19) is an infectious disease primarily affecting the lungs with a spectrum of post-viral complications. There are well-described examples of pneumonia, empyema, pneumomediastinum, and spontaneous pneumothorax cases following COVID-19 infection within the literature. However, there is insufficient evidence implicating the cause of spontaneous pneumothorax in COVID-19 recovered patients. We present a previously infected COVID-19 patient who developed a secondary spontaneous pneumothorax two weeks after recovering. A review of the literature for similar cases was limited and therefore includes a summary of recommendations. Overall, the literature establishes that pneumothorax can occur during different phases of COVID-19 in patients without a history of pulmonary disease or barotrauma and is not necessarily associated with the severity of the viral infection. As in the case of our patient, the culmination of chronic inflammatory changes and an acute exacerbation from COVID-19 further predisposed him to a secondary spontaneous pneumothorax. In summary, all cases of recovered COVID-19 patients should maintain close follow-up with their physician and seek medical attention if acute respiratory symptoms develop.