Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19: case report and literature review

Patients with coronavirus disease 2019 and spontaneous pneumothorax: a propensity-matched, multicentre case-control study

OBJECTIVES

Pneumothorax and pneumomediastinum have been frequently reported in coronavirus disease-19 (COVID-19), thus complicating the patient's overall health-care management and survival rate. The goal of this study was to evaluate the outcomes of patients with COVID-19 who developed spontaneous pneumothorax (SPN) or spontaneous pneumomediastinum (SPM).

METHODS

In this Italian multicentre retrospective cohort study, medical records of non-vaccinated COVID-19 patients, from March 2020 to May 2021, were analysed. To reduce the risk of bias due to unbalanced groups, a propensity score matching approach was applied using logistic regression to estimate propensity scores. Separate multivariable generalized linear models were then used to assess the risk of in-hospital death and other outcomes.

RESULTS

A total of 474 patients were assessed, 72 of whom developed SPN or SPM. In separate multivariable generalized linear model regression analyses of the unmatched cohort, SPN [odds ratio (OR) 2.44, 95% confidence interval (CI) 1.7-5.55; P = 0.031] was associated with an increase in the in-hospital death rate, results confirmed even after matching the 2 cohorts. SPM (OR 1.21, 95% CI 1.13-1.30, P < 0.001) and SPN (OR 1.34, 95% CI 1.26-1.43, P < 0.001) were associated with an increase in the length of hospital stay. The risk of in-hospital death also increased with age, comorbidities (classified by the Charlson comorbidity index) and smoking habits.

CONCLUSIONS

SPN in hospitalized COVID-19 patients may be associated with an increased risk of in-hospital death and prolonged hospitalization.

Pathological Presence of Free Air in the Thorax: Pneumothorax and Pneumomediastinum as a Complication of COVID-19

INTRODUCTION

The abnormal presence of free air in the thorax, pneumothorax, and pneumomediastinum are complications for critically ill patients suffering from coronavirus disease 2019 (COVID-19). The development of these events may lead to a poor prognosis and make the management of this category of patients more difficult.

STUDY DESIGN

We performed an observational retrospective study, including patients with SARS-CoV-2 infection and pneumonia who were hospitalized, to analyze the cases that developed pneumothorax or pneumomediastinum as a complication.

RESULTS

A total of 28 cases (1.51%) from 1844 patients with SARS-CoV-2 pneumonia developed pneumothorax or pneumomediastinum during hospitalization. Of them, 21 (75%) needed intensive care unit admission and ventilation, and 10 (35.71) were cured.

CONCLUSION

The male gender is more probable to be involved in the development of pneumothorax or pneumomediastinum in patients with SARS-CoV-2 pneumonia. The incidence of these events is low, and conservative treatment could provide a better outcome.

Risk factors of pneumothorax and pneumomediastinum in COVID-19: a matched case-control study

BACKGROUND

During the novel coronavirus disease-2019 pandemic, a considerable number of pneumothorax (PNX)/pneumomediastinum (PNM) associated with COVID-19 have been reported, and the incidence is higher in critically ill patients. Despite using a protective ventilation strategy, PNX/PNM still occurs in patients on invasive mechanical ventilation (IMV). This matched case-control study aims to identify the risk factors and clinical characteristics of PNX/PNM in COVID-19.

METHODS

This retrospective study enrolled adult patients with COVID-19, admitted to a critical care unit from March 1, 2020, to January 31, 2022. COVID-19 patients with PNX/PNM were compared, in a 1-2 ratio, to COVID-19 patients without PNX/PNM, matched for age, gender, and worst National Institute of Allergy and Infectious Diseases ordinal scale. Conditional logistic regression analysis was performed to assess the risk factors for PNX/PNM in COVID-19.

RESULTS

427 patients with COVID-19 were admitted during the period, and 24 patients were diagnosed with PNX/PNM. Body mass index (BMI) was significantly lower in the case group (22.8 kg/m2 and 24.7 kg/m2; P = 0.048). BMI was statistically significant risk factor for PNX/PNM in univariate conditional logistic regression analysis [odds ratio (OR), 0.85; confidence interval (CI), 0.72-0.996; P = 0.044]. For patients on IMV support, univariate conditional logistic regression analysis showed the statistical significance of the duration from symptom onset to intubation (OR, 1.14; CI, 1.006-1.293; P = 0.041).

CONCLUSIONS

Higher BMI tended to show a protective effect against PNX/PNM due to COVID-19 and delayed application of IMV might be a contributive factor for this complication.

[Spontaneous pneumomediastinum (Hamman's syndrome) with pneumorrhachis as a rare cause of acute chest pain in a young patient with acute asthma exacerbation]

Pneumomediastinum, defined as abnormal presence of air in the mediastinum, is a rare cause of acute chest pain. The condition may occur spontaneously as well as a secondary consequence of trauma or medical interventions. The spontaneous pneumomediastinum (Hamman's syndrome) is associated with a good prognosis, even without intervention. However, undelying severe conditions such as gastrointestinal perforations should be excluded. Diagnosis might be made using conventionell chest x-ray; a CT scan may give additional useful information. A subcutanous emphysema is a common finding in patients with pneumomediastinum. The presence of air in the epidural space of the spinal canal (pneumorrhachis) is a rarely seen but likewise mostly benign complication. We report a case of a young man with Hamman's syndrome and pneumorrhachis, provoked by acute asthma exacerbation; despite pronounced symptoms, his condition could be treated conservatively.

COVID-19 and pneumothorax, pneumomediastinum, subcutaneous emphysema: Analysis of risk factors

Background

In this study, we aimed to analyze the risk factors of barotrauma in patients who were followed in the intensive care unit due to novel coronavirus disease 2019 (COVID-19) pneumonia.

Methods

Between March 2020 and January 2021, a total of 261 patients (155 males, 106 females; mean age: 63.3±15.3 years; range, 11 to 91 years) who were followed in the intensive care unit due to COVID-19 pneumonia and were diagnosed with pneumothorax, pneumomediastinum, and subcutaneous emphysema were retrospectively analyzed. Demographics data of the patients, past and current medical history, clinical management, patient progress, and survival data were obtained from medical records of our hospital.

Results

Twenty-seven of the patients were diagnosed with barotrauma. A total of 88.8% of the patients were followed with intubation. The development of pneumothorax, pneumomediastinum, and subcutaneous emphysema due to barotrauma was not dependent on sex, smoking/non-smoking status, using/not using corticosteroids, or comorbid diseases. There was a significant correlation between pneumothorax, pneumomediastinum, and subcutaneous emphysema development in intubated patients with different ventilator modes. Changing the ventilator mode from synchronized intermittent mandatory ventilation to airway pressure release ventilation increased the possibility of barotrauma by 15 times.

Conclusion

Despite all lung-protective applications, barotrauma is a common complication, particularly in mechanically ventilated patients who have COVID-19 pneumonia with severe acute respiratory distress syndrome. Mechanical ventilator pressure modes should be patientspecific and followed carefully and frequently for the risk of barotrauma.

Pneumothorax/pneumomediastinum and pre-existing lung pathology in ventilated COVID-19 patients: a cohort study

Background

There is an increasing number of reports on developing pneumothorax/pneumomediastinum among severe acute respiratory syndrome coronavirus disease 2019 (SARS-COVID-19) patients. The aim of our study was whether pre-existing diffuse lung pathology increases visceral pleural vulnerability resulting in pneumomediastinum and pneumothorax among mechanically ventilated COVID-19 patients?

Methods

A total of 138 consecutive COVID-19 patients admitted to the Intensive Care Unit of Petz Aladár University Teaching Hospital between 1st March 2020 and 1st February 2021 were included. Sixty/138 (43.48%) patients had one or more computer tomography scans of the chest. Analysis was focused on the image defined lung conditions during artificial ventilation.

Results

Thirteen out of 60 ventilated patients developed pneumothorax or pneumomediastinum proven by computer tomography (9.42%). Three/13 patients suffered from pre-existing lung parenchyma pathology, while 10/13 had only COVID-19 infection-related image abnormality. Forty-three/60 patient had healthy lung pre-COVID. Kruskal-Wallis test, Spearman correlation and Cox regression calculations did not reveal any statistically significant result proving increased vulnerability during pressure support therapy and visceral pleural breakdown in patients with pre-existing lung pathologies.

Conclusions

Pre-existing lung pathology does not increase the risk of onset of pneumothorax or pneumomediastinum in comparation with previously healthy lungs of ventilated COVID-19 patients.

A Case of Spontaneous Mediastinal and Subcutaneous Emphysema in a Patient with HIV-Infected Pneumonia

BACKGROUND

Acquired immunodeficiency syndrome is a chronic infectious disease with high mortality and is caused by the Human Immunodeficiency Virus (HIV). Pneumonia caused by HIV is common, but it rarely causes spontaneous mediastinal and subcutaneous emphysema.

CASE PRESENTATION

A 21-year-old man with severe pneumonia was hospitalized owing to dyspnea that had been persisting for 1 day; blood test results confirmed HIV infection. Initial chest Computed Tomography (CT) did not reveal mediastinal or subcutaneous emphysema. However, after 21 days of treatment, the patient experienced discomfort in the neck region and experienced the feeling of snowflakes on applying pressure. Chest CT showed mediastinal and subcutaneous emphysema, located in the bilateral cervical roots, anterior upper chest wall, left axillary chest wall, mediastinum, and other parts. Metagenomic Next Generation Sequencing (mNGS) of the sputum and blood samples suggested multiple pathogenic infections. Antiinfection treatment was initiated, and changes in the patient's condition were monitored. The patient's subcutaneous emphysema improved during the follow-up.

CONCLUSION

In HIV-infected patients with sudden mediastinal and subcutaneous emphysema, mNGS can be used to determine the etiological agent during symptomatic treatment. Targeted antipathogen therapy is helpful in improving the condition of patients with subcutaneous emphysema.

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.

Diagnostic and Therapeutic Characteristics in Patients with Pneumotorax Associated with COVID-19 versus Non-COVID-19 Pneumotorax

Introduction: Pneumothorax is a condition that usually occurs in thin, young people, especially in smokers. It is an unusual complication of COVID-19 disease that can be associated with worse results. This disease can occur without pre-existing lung disease or without mechanical ventilation. Materials and Methods: We present a monocentric comparative retrospective study of diagnostic and treatment analysis of two groups of patients diagnosed with COVID-19 and non-COVID-19 pneumothorax. All patients included in this study underwent surgery in a thoracic surgery department. The study was conducted over a period of 18 months. It included 34 patients with COVID-19 pneumothorax and 42 patients with non-COVID-19 pneumothorax. Results: The clinical symptoms were more intense in patients with COVID-19 pneumothorax. We found that the patients with COVID-19 had significantly more respiratory comorbidities. Diagnostic procedures include chest CT exam for both groups. Laboratory findings showed that increasing values for the analyzed data were consistent with the deterioration of the general condition and the appearance of pneumothorax in the COVID-19 group. The therapeutic attitude regarding the non-COVID-19 group was to eliminate the air from the pleural cavity and surgical approach to the lesion that determined the occurrence of pneumothorax. The group of patients with COVID-19 pneumothorax received systemic treatment, and only minimal pleurotomy was performed. The surgical approach did not alter patients’ survival. Conclusions: Careful monitoring of the patient’s clinic and laboratory tests evaluating the degradation of the lung parenchyma, correlated with the imaging examination (chest CT) is mandatory and reduces COVID-19 complications. Early imaging examination starts an effective diagnosis and treatment management. In severe COVID-19 pneumothorax cases, the pneumothorax did not influence the evolution of COVID-19 disease. When we found that the general condition worsened with the rapid progression of dyspnea and the deterioration of the general condition, and we found that it represented the progression or recurrence of pneumothorax.

Air leaks in COVID-19

Coronavirus disease 2019 (COVID-19) continues to create havoc and may present with myriad complications involving many organ systems. However, the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected. There is a high incidence of air leaks in patients with COVID-19, leading to acute worsening of clinical condition. The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and un-derlying lung disease. The exact pathophysiology of air leaks with COVID-19 remains unclear, but multiple factors may play a role in their development. A significant proportion of air leaks may be asymptomatic; hence, a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality. These air leaks may even develop weeks to months after the disease onset, leading to acute deterioration in the post-COVID period. Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.

Hereditary Thrombophilia in the Era of COVID-19

Thrombophilia, also called hypercoagulability or prothrombotic condition, usually reflects a certain imbalance that occurs either in the coagulation cascade or in the anticoagulation/fibrinolytic system. A similar imbalance may be induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thrombotic complications are associated with multiorgan failure and increased mortality. In this context, activation of coagulation and thrombocytopenia appeared as prognostic markers in COVID-19. Our work provides a structured and updated analysis of inherited thrombophilia and its involvement in COVID-19, emphasizing the importance of diagnosing and initiating thromboprophylaxis. Since the state of hypercoagulation is directly correlated with COVID-19, we consider that studies on the genetic profiles of proteins involved in thrombophilia in patients who have had COVID-19 and thrombotic events are of great importance, both in treating and in preventing deaths due to COVID-19.

A Dangerous Duo: Spontaneous Pneumomediastinum and Venous Thromboembolism at Presentation in a Patient with COVID-19 Pneumonia

Background

Coronavirus disease 2019 (Covid-19) is associated with spontaneous pneumomediastinum (SPM) predominantly in those after positive pressure ventilation (PPV) support. Additionally, many cases of venous thromboembolism (VTE) in COVID-19 patients were described. Our case is the first to describe SPM and VTE present on admission in a patient with Covid -19 pneumonia.

Case report

A 53-year-old man presented to the hospital with escalating dyspnea. Two weeks prior to this visit, he had been evaluated in an ambulatory setting and was started on antibiotics and systemic steroids. In the hospital, this patient was found to be in acute hypoxic respiratory failure and was placed on noninvasive PPV. Diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) test from nasopharyngeal swab specimen. Chest computed tomography (CT) scan revealed multi-lobar pulmonary emboli (PE) and subcutaneous emphysema with pneumomediastinum. The patient was managed conservatively. He never required closed invasive mechanical ventilation. Subsequent serial imaging displayed the resolution of SPM.

Conclusion

The association between VTE and COVID-19 has been established. This report brings attention to SPM as an additional important complication of COVID-19, even in patients without pre-existing predisposing pathology or exposure to PPV.

Risk Factors, Characteristics, and Outcome in Non-Ventilated Patients with Spontaneous Pneumothorax or Pneumomediastinum Associated with SARS-CoV-2 Infection

Background and Objectives

Spontaneous pneumothorax (SP) and spontaneous pneumomediastinum (SPM) have frequently been cited as complications associated with coronavirus disease 2019 (COVID-19) pneumonia, with especially poor prognosis in mechanically ventilated patients. The current literature is controversial regarding the potential risk factors for developing SP or SPM (SP-SPM) in non-ventilated COVID-19 patients. Our research addressed a twofold objective: (a) to investigate the characteristics of patients with SP-SPM (both with and without COVID-19) and compare them to patients with sole COVID-19; (b) to quantify the risk of in-hospital mortality associated with SP-SPM and COVID-19.

Patients and Methods

A retrospective case–control study was conducted in the emergency departments (ED) of two tertiary hospitals in Timisoara, Romania, over one year (1st April 2020‒31st March 2021; 64,845 records in total) and 70 cases of SP-SPM were identified (both SARS-CoV-2 positives and negatives). The control group comprised COVID-19 patients with no SP-SPM, included at a 2:1 ratio. Logistic regression was employed to quantify the in-hospital mortality risk associated with age, SP-SPM, and COVID-19.

Results

SP-SPM and COVID-19 were connected with prolonged hospitalization, a higher percentage of intensive care admission, and a higher mortality. SP-SPM increased the odds of death by almost four times in patients of the same age, gender, smoking status, and SARS-CoV-2 infection: OR = 3.758, 95% CI (1.443–9.792). Each additional year of age added 9.4% to the mortality risk: OR = 1.094, 95% CI (1.054–1.135).

Conclusion

ED physicians should acknowledge these potential risks when attending COVID-19 patients with SP-SPM.

The analysis of pleural complications of COVID-19 pneumonia

Background/aim

As the number of case reports related to the new type of coronavirus (COVID-19) increases, knowledge of and experience with the virus and its complications also increase. Pleural complications are one relevant issue. We aimed in this study to analyze pleural complications, such as pneumothorax, pneumomediastinum, and empyema, in patients hospitalized with the diagnosis of COVID-19 pneumonia.

Materials and methods

The files of patients who have pleural complications of COVID-19 pneumonia and were consulted about thoracic surgery between March 2020 and December 2020 were retrospectively reviewed. The data of the patients were analyzed according to age, sex, length of stay, treatment method for pleural complications, mortality, severity of COVID-19 pneumonia, tube thoracostomy duration, and presence of a mechanical ventilator.

Results

A total of 31 patients fulfilling the inclusion criteria were included in the study. There were 11 female (35.5%) and 20 male (65.5%) patients. The most common complication was pneumothorax in 20 patients (65%). The median duration of hospitalization was 22 days and the mortality rate was 71%. Mortality was significantly higher in patients on mechanical ventilation (p = 0.04).

Conclusion

The mortality rate is very high in patients with pleural complications of COVID-19 pneumonia. Pneumothorax is a fatal complication in critically ill patients with COVID-19 pneumonia.

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.

Tension Pneumomediastinum: A life-threatening condition in patients with COVID-19

Tension pneumomediastinum (TPM) is a rare but potentially fatal clinical entity. TPM leads to the leakage of air into the mediastinal cavity and increased pressure in thoracic vessels, respiratory tract, and the heart. Herein, this report presents a series of five cases of coronavirus disease-2019 (COVID-19) that caused acute respiratory distress syndrome (ARDS) and TPM. All patients were male who had severe ARDS with a secondary lung infection that required invasive ventilation and had moderate positive-end expiratory pressure. All patients required vasopressors to maintain hemodynamics, and two patients needed decompression with chest drains. One patient received extracorporeal membrane oxygenation therapy. Three patients had cardiac arrest, and two patients died; thus, the mortality rate was 40%. Patients with COVID-19 pneumonia with ARDS required invasive ventilation and prone positioning. Secondary lung infection can cause TPM, and TPM may cause cardiac arrest. Management should be prompt recognition and decompression with the insertion of drains, and conservative treatment is required in stable cases. Protocols for the management of pneumomediastinum and TPM may enable early detection, earlier management, and prevention of TPM.

Clinical Course of Mechanically Ventilated COVID-19 Patients With Pneumothoraces

Introduction Pneumothoraces in mechanically ventilated patients with COVID-19 indicate severe lung damage from inflammatory injury and barotrauma. These patients have a high mortality rate, and additional factors may further alter their clinical course. Methods We conducted a retrospective review of patients admitted to 11 public hospitals in New York City between March 6 and April 9, 2020, diagnosed with COVID-19. We identified 39 patients who developed pneumothoraces immediately after intubation or after a period of time on mechanical ventilation. Our study population was divided into various groups using demographic and clinical characteristics. Statistical analyses were conducted using SPSS software (IBM Inc., Armonk, USA) and paired t-tests to compare clinical outcomes between the various groups. P values < 0.05 were considered statistically significant. Results Our population was comprised of 28 male (72%) and 11 female patients; 36 out of 39 patients (92.3%) died with a median time of 10 days from admission to death and a median time of 2 days from pneumothorax to death. The remaining three were discharged home or to another facility. Pneumothoraces developed immediately after intubation in 18 patients and after a period of time on mechanical ventilation in 21 patients. Factors associated with a worse clinical course included age greater than 65 years (time from admission to pneumothorax 4.81 vs 8.35 days; p = 0.011) and presence of one or more comorbidities (time from admission to intubation 2.3 days vs 4.8 days; p = 0.041). Other factors that may worsen clinical course include previous smoking (time from admission to pneumothorax 4.4 vs 8.54 days; p = 0.074) and use of positive end-expiratory pressure (PEEP) greater than 15 cm H₂O (time from intubation to pneumothorax 3.89 vs 6.42 days; p = 0.14). Conclusions Based on the findings in our retrospective review, COVID-19 patients who develop pneumothoraces on mechanical ventilation have a mortality rate in excess of 90%. Older patients and those with comorbidities have a more fulminant clinical course.

Pneumomediastinum and Pneumothorax as Relevant Complications of Sub-Intensive Care of Patients with COVID-19: Description of a Case Series

Lung failure has been the most common cause of hospitalization for COVID-19. Yet, bilateral interstitial pneumonia has not been the only cause of lung failure of these inpatients, and frequently they develop other illnesses associated with COVID-19. Pulmonary embolism has been the most looked for in the world, but rarely other pneumological diseases, such as pneumothorax and pneumomediastinum, have been described and associated with a worsening prognosis. We here report our clinical experience associated with the occurrence of pneumothorax and pneumomediastinum in a cohort of inpatients hospitalized in our division of medicine in a regular ward or in a sub-intensive ward.

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.

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.

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.

Pneumomediastinum associated with severe pneumonia related to COVID-19: diagnosis and management

BACKGROUND

Pneumomediastinum (PNM) can develop as a severe complication of severe COVID 19 and may be correlated with greater morbidity and mortality. PNM is a rarely reported complication in COVID-19 patients and usually associated with endotracheal intubation.

METHODS

Our aim is to describe the characteristics of patients with PNM in twenty-one patients with COVID-19 related pneumonia and acute respiratory failure in a retrospective case series.

RESULTS

Twenty-one patients were diagnosed, two were treated with high flow nasal cannula, five with non invasive ventilation and four with invasive mechanical ventilation. In four cases PNM was massive PNM was often associated to subcuatneous emphysema; more rarely associated also with pneumothorax. Conservative management was the most used therapeutic strategy.

CONCLUSIONS

PNM should is s serious but not extremely rare complication of severe forms of pulmonary involvement of COVID 19. The clinician should consider this rare complication; moreover, we advise careful attention when clinicians start mechanical ventilation.

Spectrum of atypical pulmonary manifestations of COVID-19 on computed tomography

Background

The typical CT manifestations of COVID-19 pneumonia include ground-glass opacity (GGO) with or without consolidation and superimposed interlobular septal thickening. These are often rounded in morphology and frequently bilateral, multilobar, posterior, peripheral, and basilar in distribution. The various atypical CT features of COVID-19 are seldom described in the literature. The study aims to enumerate the atypical pulmonary CT features in patients with COVID-19 pneumonia in correlation with the disease severity.

Results

A total of 298 confirmed cases of COVID-19 pneumonia with positive reverse transcription polymerase chain reaction (RT-PCR) who underwent chest CT scans were retrospectively evaluated. The cohort included 234 (78.5%) men and 64 (21.5%) women and the mean age was 53.48 ± 15.74 years. The most common presenting symptoms were fever [n = 197 (66.1%)] and cough [n = 139 (46.6%)]. Out of 298 cases of COVID-19 pneumonia, 218 cases (73.1%) showed typical CT features while 63 cases (21.1%) showed atypical CT features with concurrent classical findings and the remaining 17 cases (5.8%) were normal. Among the atypical CT features, the most common was pulmonary cysts [n = 27 (9%)]. The other features in the order of frequency included pleural effusion [n = 17 (5.7%)], nodules [n = 13 (4.3%)], bull’s eye/target sign[n = 4 (1.3%)], cavitation [n = 3 (1.0%)], spontaneous pneumothorax [n = 2 (0.6%)], hilar lymphadenopathy [n = 2 (0.6%)], spontaneous pneumo-mediastinum with subcutaneous emphysema [n = 1 (0.3%)], Halo sign [n = 1 (0.3%)], empyema [n = 1 (0.3%)] and necrotizing pneumonia with abscess [n = 1 (0.3%)].

Conclusion

CT imaging features of COVID-19 pneumonia while in a vast majority of cases is classical, atypical diverse patterns are also encountered. A comprehensive knowledge of various atypical presentations on imaging plays an important role in the early diagnosis and management of COVID-19.

Case Report: Massive Spontaneous Pneumothorax-A Rare Form of Presentation for Severe COVID-19 Pneumonia

Background and Objectives: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a viral disease that is spreading worldwide and became a pandemic. Although most of the time, the symptoms of the infection are flu like, a percentage of patients develop severe forms, along with severe complications. Many of them are known among front-line health workers, but the number of uncommon presentations and complications has increased. This case report aims to alert healthcare workers on less common forms of presentation, and to introduce this differential diagnosis in the evaluation of patients with COVID-19, given the increasing occurrence of pneumothorax in patients who are not mechanical ventilated. Case presentation: A 57-year-old female patient came to the Emergency Department (ED) by ambulance, with acute respiratory failure. She had SpO₂ (peripheral O₂ saturation ) = 43% on room air at home, and 86% on admission in ED after oxygen delivery (on a reservoir mask). SARS-CoV-2 infection was suspected based on symptoms that started three days ago (fever, dry cough, dyspnea, and fatigability). Blood was taken for lab tests, pharyngeal and nasal swabs for the reverse transcription–PCR (RT-PCR) test, and native computed tomography (CT) was scheduled. The thoracic CT scan showed massive right pneumothorax, partially collapsed lung, multiple bilateral lung infiltrates with a ground glass aspect and the RT-PCR test came back positive for SARS-CoV-2 infection. Despite the prompt diagnosis and treatment of pneumothorax (thoracostomy was performed and the drain tube was placed), the patient died after a long hospitalization in the intensive care unit. Conclusion: Secondary spontaneous pneumothorax (SSP), as a complication in severe forms of COVID-19 pneumonia, especially in female patients without risk factors is rare, and early diagnosis and treatment are essential for increasing the survival chances of these patients.

Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease

BACKGROUND

Pulmonary radiological findings of the novel coronavirus disease 2019 (COVID-19) have been well documented and range from scattered ground-glass infiltrates in milder cases to confluent ground-glass change, dense consolidation, and crazy paving in the critically ill. However, lung cavitation has not been commonly described in these patients. The objective of this study was to assess the incidence of pulmonary cavitation in patients with COVID-19 and describe its characteristics and evolution.

METHODS

We conducted a retrospective review of all patients admitted to our institution with COVID-19 and reviewed electronic medical records and imaging to identify patients who developed pulmonary cavitation.

RESULTS

Twelve out of 689 (1.7%) patients admitted to our institution with COVID-19 developed pulmonary cavitation, comprising 3.3% (n = 12/359) of patients who developed COVID-19 pneumonia, and 11% (n = 12/110) of those admitted to the intensive care unit. We describe the imaging characteristics of the cavitation and present the clinical, pharmacological, laboratory, and microbiological parameters for these patients. In this cohort six patients have died, and six discharged home.

CONCLUSION

Cavitary lung disease in patients with severe COVID-19 disease is not uncommon, and is associated with a high level of morbidity and mortality.