Pneumomediastinum and subcutaneous emphysema associated with pandemic (H1N1) influenza in three children

Extracorporeal membrane oxygenation rescue for severe pneumocystis pneumonia with the Macklin effect: a case report

Background

Pneumocystis jirovecii pneumonia (PJP) in an immunocompromised host is often associated with the Macklin effect, which can progress to spontaneous pneumomediastinum (SPM), subcutaneous emphysema (SCE), and pneumothorax (PNX). Diagnosing the causative organism of these conditions in non-HIV infected patients and treating hypoxemia while preventing further lung damage can be challenging. This study examines the case of a non-HIV infected male with SPM, SCE, and PNX secondary to severe Pneumocystis jirovecii (PJ) infection.

Case presentation

A 53-year-old male with pure red cell aplasia (PRCA) was admitted with fever, dry cough, and shortness of breath. His respiratory function progressively deteriorated due to the development of SPM, SCE, and PNX, eventually requiring endotracheal intubation and invasive ventilation. As a result of high pressure in his airways occasioned by lung recruitment maneuvers, his pulmonary parameters worsened, necessitating veno-venous (VV) extracorporeal membrane oxygenation (ECMO) therapy. The early initiation of VV-ECMO facilitated ultra-protective lung ventilation and prevented the progression of SPM, SCE, and PNX. Traditional diagnostic assays were unrevealing, whereupon the patient resorted to the metagenomic next-generation sequencing technology for uncovering potential pathogens. Consequently, we detected a significantly higher infection by PJ in the patient’s bronchoscopy lavage fluid. Finally, the patient was successfully treated with appropriate antimicrobials and was decannulated after nine days of ECMO support.

Conclusions

SPM, SCE, and PNX are rare clinical manifestations of PJP. However, they can be considered as poor prognostic factors of the infection. Physicians should, therefore, be alert to the possibility of PJP in immunocompromised patients.

Epidemiology, Risk Factors and Outcomes of Pneumomediastinum in Patients with Coronavirus Disease 2019: A Case-Control Study

Background: Since the beginning of the ongoing Coronavirus Disease 2019 (COVID-19) pandemic, pneumomediastinum has been reported in patients with COVID-19 pneumonia and acute respiratory distress syndrome. It has been suggested that pneumomediastinum may portend a worse outcome in such patients although no investigation has established this association definitively. Research Question: We hypothesized that the finding of pneumomediastinum in the setting of COVID-19 disease may be associated with a worse clinical outcome. The purpose of this study was to determine if the presence of pneumomediastinum was predictive of increased mortality in patients with COVID-19. Study Design and Methods: A retrospective case-control study utilizing clinical data and imaging for COVID-19 patients seen at our institution from 3/7/2020 to 5/20/2020 was performed. 87 COVID-19 positive patients with pneumomediastinum were compared to 87 COVID-19 positive patients without pneumomediastinum and to a historical group of patients with pneumomediastinum during the same time frame in 2019. Results: The incidence of pneumomediastinum was increased more than 6-fold during the COVID-19 pandemic compared to 2019 (P = <.001). 1.5% of all COVID-19 patients and 11% of mechanically ventilated COVID-19 patients at our institution developed pneumomediastinum. Patients who developed pneumomediastinum had a significantly higher PEEP and lower P/F ratio than those who did not (P = .002 and .033, respectively). Pneumomediastinum was not found to be associated with increased mortality (P = .16, confidence interval [CI]: 0.89-2.09, 1.37). The presence of concurrent pneumothorax at the time of pneumomediastinum diagnosis was associated with increased mortality (P = .013 CI: 1.15-3.17, 1.91). Conclusion: Pneumomediastinum is not independently associated with a worse clinical prognosis in COVID-19 positive patients. The presence of concurrent pneumothorax was associated with increased mortality.

Thoracic Surgery Consultations in COVID-19 Critically Ill Patients: Beyond Conservative Approach

Introduction

Iatrogenic pneumothoracis, barotraumas, and tracheoesophageal fistulae, especially after prolonged intubation, and tracheal stenosis are all entities involving thoracic surgeons' consultation and management. With the surge of COVID-19 cases particularly in the critical care settings, various types of complications have been observed that require intervention from thoracic surgeons.

Methods and Materials

A retrospective study was conducted in an academic healthcare institute in the Eastern Province of Saudi Arabia. We included all COVID-19 cases admitted to ICU in the period between March 15, 2020, and August 15, 2020, requiring thoracic surgery consultation and management. Non-COVID-19 critical cases and iatrogenic pneumothorax were excluded.

Results

Of 122 patients who were admitted to ICU with COVID-19, 18 patients (14.75%) required thoracic surgery consultation and management. We discovered a significant association between the outcomes and reintubation rates and the rate of pneumothorax occurrence. The survival analysis showed improvement in patients who had thoracostomy tube insertion as a management than the group who were treated conservatively. On the other hand, there was a significant difference between the COVID ICU group who had thoracic complication and those who did not regarding the length of hospital stay.

Conclusion

Noniatrogenic pneumothorax, subcutaneous emphysema, and mediastinal emphysema are well-known thoracic entities, but their presence in the context of COVID-19 disease is a harbinger for worse prognosis and outcomes. The presence of pneumothorax may be associated with better prognosis and outcome compared to surgical and mediastinal emphysema.

A Child with Influenza A and Large Pneumatocele

: Necrotizing pneumonia (NP) is a rare complication of community-acquired pneumonia, which occurs in patients with viral pneumonia such as influenza and secondary bacterial infection. We present a five-year-old boy with cough and dyspnea and low SpO2, who was admitted to PICU. He was intubated, and two-sided chest tubes were placed because of pleural effusion. Nasopharyngeal RT-PCR for H1N1 was positive. Subcutaneous and mediastinal emphysema and a large pneumatocele developed concomitantly, and the patient underwent three times percutaneous aspiration of pneumatocele under anesthesia and CT scan guide without surgery. The size of the pneumatocele decreased, and the patient was extubated. After one month of admission, he was discharged in good condition and no pulmonary sequela.

Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review

Spontaneous pneumomediastinum (SPM) and pneumothorax (PNX) unrelated to positive pressure ventilation has been recently reported as an unusual complication in cases of severe COVID-19 pneumonia. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. We present a case of COVID-19 pneumonia complicated on day 13 post admission by SPM, PNX and subcutaneous emphysema in a patient with no identifiable risk factors for such complication. The patient received medical treatment for his COVID-19 infection without the use of an invasive or non-invasive ventilator. Moreover, he is a non-smoker with no lung comorbidities and never reported a cough. He was eventually discharged home in stable condition. A comprehensive literature review revealed 15 cases of SPM developing in patients with COVID-19 pneumonia.

Spontaneous pneumomediastinum in H1N1 infection: uncommon complication of a common infection

H1N1 viral infection leads to complications, such as pneumonia, respiratory failure, myocarditis and encephalitis. Spontaneous pneumomediastinum (SPM) is an extremely rare consequence of H1N1 infection and such cases have been sparsely reported. SPM is identified only by a careful clinical examination and obtaining a timely roentgenogram. We report a case of a young male admitted with H1N1 infection complicated by pneumomediastinum. He was treated successfully with oseltamivir, high-flow oxygen and prompt care in the intensive care unit.

Spontaneous pneumomediastinum occurring in the SARS-COV-2 infection

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Spontaneous mediastinum (SPM) is a rare presentation in COVID-19.

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SPM in COVID-19 is secondary to the increase of alveolar pressure through coughing or to alveolar rupture due to alveolar membrane damage.

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The association of pneumomediastum and an extensive lesion on CT indicates severe destruction of the alveolar membrane.

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SPM is a potential indicator of worsening clinical outcome.

We report the case of a 23 year old female admitted for management of infection by the SARS-COV-2. The chest CT found a spontaneous pneumomediastinum that resorbed over 7 days with a good clinical outcome. We will discuss the mechanism underlying the occurrence of spontaneous pneumomediastinum during a COVID-19 pneumonia.

Pneumomediastinum complicating adult-onset measles

Adult-onset measles is rare in the UK, particularly in patients with a complete vaccination history.We present a case of a UK-born patient who received all childhood vaccinations, had no history of recent travel or unwell contacts who was diagnosed with measles complicated by pneumomediastinum. This case highlights the need to consider measles in any patient presenting with a constellation of a macular rash, fever and conjunctivitis, regardless of vaccination status. The nature of the rash can provide an important clue to the diagnosis. Liaison with infection specialists facilitates early diagnosis, allowing for appropriate initial investigations, improving clinical management and early infection control precautions being instituted.

Spontaneous pneumomediastinum, pneumoretroperitoneum, and cervicofacial subcutaneous emphysema after repeatedly and forcefully blowing into a bottle

Spontaneous pneumomediastinum (SPM) is an uncommon, self-limiting condition associated with increased intra-thoracic pressure resulting in alveolar rupture. Search of the literature revealed no detailed case report about a 26-year-old psychiatric patient who repeatedly and forcefully blew air into a bottle for 5 days resulting in a combined condition of spontaneous pneumoretroperitoneum, pneumomediastinum, and cervicofacial subcutaneous emphysema. It is crucial to find a primary source and treat appropriately. Psychiatric patients may have psychotic behaviors mimicking Valsalva's maneuver that increases intra-thoracic pressure and causing SPM. Optimal medications should be given to control psychotic behaviors. Family members and caregivers should be explained about this unusual behavior so that they can prevent this rare condition.

Spontaneous pneumomediastinum: A complication of swine flu

The occurrence of spontaneous pneumomediastinum in swine flu, or H1N1 influenza A infection, is a rare phenomenon and only few cases have been reported in children. We describe a case of spontaneous pneumomediastinum in adult infected with swine flu.

Pneumomediastinum and soft tissue emphysema in pediatric hanging

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3-year-old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autopsy.

Subcutaneous emphysema as the first relevant clinical sign of complicated tubercular lymph node disease in a child

BACKGROUND

Children make up a significant proportion of the global tuberculosis (TB) caseload, and experience considerable TB-related morbidity and mortality. Unfortunately, it is not easy to diagnose TB in the first years of life because of the diversity of its clinical presentation and the non-specific nature of most of its symptoms.

CASE PRESENTATION

A 26-month-old male child was admitted to hospital because of the sudden onset of rapidly increasing swelling of the neck, face and upper trunk a few hours before. Upon admission, his temperature was 36.5°C, pulse rate 120/min, respiratory rate 36/min, and O2 saturation 97% in air. Palpation revealed subcutaneous emphysema (SE) over the swollen skin areas, and an examination of the respiratory system revealed crepitations in the left part of the chest without any significant suggestion of mediastinal shift. Chest radiography showed enlargement of the left lung hilum with pneumomediastinum and diffuse SE. Bronchoscopy was carried out because of the suspicion that the SE may have been due to the inhalation of a peanut. This excluded the presence of a foreign body but showed that the left main bronchus was partially obstructed with caseous material and showed significant signs of granulomatous inflammation on the wall. Contrast-enhanced computed tomography of the lungs confirmed the SE and pneumomediastinum, and revealed bilateral hilum lymph node disease with infiltration of the adjacent anatomical structure and a considerable breach in the left primary bronchus wall conditioning the passage of air in the mediastinum and subcutaneous tissue. As a tuberculin skin test and polymerase chain reaction for Mycobacterium tuberculosis on bronchial material and gastric aspirate were positive, a diagnosis of TB was made and oral anti-TB therapy was started, which led to the elimination of M. tuberculosis and a positive clinical outcome.

CONCLUSIONS

This is the first case in which SE was the first relevant clinical manifestation of TB and arose from infiltration of the bronchial wall secondary to caseous necrosis of the hilum lymph nodes. Physicians should be aware of the fact that SE is one of the possible initial signs and symptoms of early TB infection, and act accordingly.