Spontaneous pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema in a patient with COVID-19

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.

Iatrogenic Barotrauma in COVID-19-Positive Patients: Is It Related to the Pneumonia Severity? Prevalence and Trends of This Complication Over Time

COVID-19 has attracted worldwide attention ever since the first case was identified in Wuhan (China) in December 2019 and was classified, at a later time, as a public health emergency of international concern in January 2020 and as a pandemic in March 2020. The interstitial pneumonia caused by COVID-19 often requires mechanical ventilation, which can lead to pulmonary barotrauma. We assessed the relationship between pneumonia severity and the development of barotrauma in COVID-19-positive patients mechanically ventilated in an intensive care unit; we therefore analyzed the prevalence of iatrogenic barotrauma and its trends over time during the pandemic in COVID-19-positive patients undergoing mechanical ventilation compared to COVID-19-negative patients, making a distinction between different types of ventilation (invasive mechanical ventilation vs. noninvasive mechanical ventilation). We compared CT findings of pneumomediastinum and pneumothorax in 104 COVID-19-positive patients hospitalized in an intensive care unit and 101 COVID-19-negative patients undergoing mechanical ventilation in the period between October 2020 and December 2021. The severity of pneumonia was not directly correlated with the development of barotrauma. Furthermore, a higher prevalence of complications due to barotrauma was observed in the group of mechanically ventilated COVID-19-postive patients vs. COVID-19-negative patients. A higher rate of barotrauma was observed in subgroups of COVID-19-positive patients undergoing mechanical ventilation compared to those treated with invasive mechanical ventilation. The prevalence of barotrauma in COVID 19-positive patients showed a decreasing trend over the period under review. CT remains an essential tool in the early detection, diagnosis, and monitoring of the clinical course of SARS-CoV2 pneumonia; in evaluating the disease severity; and in the assessment of iatrogenic complications such as barotrauma pathology.

Pneumomediastinum and Pneumopericardium as Uncommon Complications of COVID-19 Infection: A Review Article

There is an emerging body of literature describing an increasing incidence of pneumomediastinum and, to a lesser extent, pneumopericardium as a complication of COVID-19. However, the literature lacks information regarding patients' characteristics and a general view of this unusual condition. The purpose of this paper is to summarize the current literature on this phenomenon. In this study, we summarize the risk factors/etiology, imaging modalities, management, and prognosis of known cases in the literature. In total, 48 articles were included in the study, ranging from case reports to case series. Most patients were male (83.3%). The overall mortality rate was 27.1% and the recovery rate was 62.5%.

Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema: Radiological aspects of rare COVID-19 complications in 3 patients

Spontaneous pneumomediastinum (SPM), pneumothorax (PNX) and subcutaneous emphysema are rare complications of COVID-19 pneumonia. In this paper we describe 3 cases of COVID-19 pneumonia complicated by SPM with or without PNX. Patient 1 was a 56-year-old woman whose medical history was significant for chronic leukemia. She presented with typical clinical signs of COVID-19 pneumonia and after 2 weeks of hospitalization she developed SPM and subcutaneous emphysema. The management of pneumomediastinum (PNM) was conservative and follow-up computed tomography showed resolution of PNM. Patient 2 was a 67-year-old man presenting with fever, cough and dyspnea. Computed tomography pulmonary angiography was performed after 2 weeks of hospitalization and showed bilateral peripheral consolidations together with massive PNM and right-sided PNX. Thoracic drainage catheter was inserted in his right chest. Despite all supportive care, the patient succumbed to illness. Patient 3 was a 74-year-old man who was admitted to our hospital with COVID-19 pneumonia and spontaneous right-sided PNX. A thoracic drainage catheter was inserted immediately and then removed after ten days which has led to progression of subcutaneous emphysema, PNX and newly diagnosed PNM. Patient was carefully monitored for the next 2 weeks. Follow-up chest x-ray showed regression of PNM and PNX. SPM, PNX and subcutaneous emphysema are rare complications of COVID-19 pneumonia. Increased alveolar pressure and diffuse alveolar injury in severe COVID-19 pneumonia may make the alveoli more prone to rupturing which leads to gas dissemination along the peribronchovascular sheath to the mediastinum. Most cases of SPM and PNX resolve with conservative management.

The Macklin Effect in COVID-19

From the mere outlook of the ongoing pandemic, coronavirus (severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) seems to target mainly the respiratory system, but more evolving evidence has advocated its multi-organ involvement. While various complications have been reported in coronavirus disease 2019 (COVID-19) patients, spontaneous pneumomediastinum (SP) remains an uncommon complication.

Typical Covid-19 case with primary pneumomediastinum in a 37 year old male

We report the case of a 37-year-old man who was admitted to Baqiyatallah hospital in Tehran (Iran) for retrosternal pain, fever, fatigue, dyspnoea and severe non-productive cough. The patient was subsequently confirmed as positive for COVID-19 at real-time polymerase chain reaction (RT-PCR) test. Chest computed tomography (CT) revealed also the presence of pneumomediastinum. This case highlights the importance of chest CT imaging for COVID-19 pneumonia to detect co-existing conditions as pneumomediastinum.

Simultaneous spontaneous pneumomediastinum and pneumopericardium in a critically ill patient with COVID-19

Case in the paper is of a 24-year-old woman presenting to Baqiyatallah hospital, Tehran, Iran with the occasional fever, weakness, myalgia, fatigue, body aches, and headache who was diagnosed with Coronavirus disease-19 (COVID-19) PCR test. Chest computed tomography (CT) showed spontaneous pneumomediastinum (SPM) and pneumopericardium (SPP). Here, we described SPM, and SPP in a patient with COVID-19, presenting a severe course of the disease.

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.