COVID-19 ARDS-related pneumomediastinum and pneumothorax.

Dear Editor,

The current coronavirus disease (COVID-19) pandemic has already affected more than 60 million people and it is still ongoing. The most common radiological manifestation of COVID-19 is bilateral peripheral multilobar ground-glass opacities involving lower and middle lobes. Spontaneous pneumothorax with pneumomediastinum has been rarely reported in the literature with this disease.2, 3, 4 Herein, we present a case of a middle-aged female with COVID-19 acute respiratory distress syndrome (ARDS) and spontaneous pneumothorax and pneumomediastinum. Pneumomediastinum as a complication of COVID-19 has not been reported from India.

A 54-year-old female patient known case of rheumatoid arthritis presented with a history of fever, vomiting and generalised malaise of 3 days duration. On arrival, she was conscious, oriented but was tachypnoeic (respiratory rate—32/min) and hypoxic at room air (SpO2—90%). She had bibasal crackles on auscultation. Her nasopharyngeal and throat swab was positive for COVID-19 by reverse transcription polymerase chain reaction. Her investigation revealed the following: Hb—12.9 mg/dL, TLC—13,600/cmm, neutrophil/lymphocyte ratio—9.8, platelets—3.25 lacs/cumm and urea/creatinine—64/1.4 mg/dL. Her liver function tests and coagulation profile were within normal limits. However, her inflammatory markers were raised (LDH—632 IU/L, serum ferritin—1122 ng/mL and D-Dimer—7 mcg/mL). The chest roentgenogram showed bilateral air space opacities in the mid and lower zones (Fig. 1). She was diagnosed with COVID-19 pneumonia with type-1 respiratory failure and was managed with injectable steroids (methylprednisolone 1 mg/kg twice daily) along with antibiotics, low molecular weight heparin, oxygen therapy via face mask, 2 doses of convalescent plasma and awake proning as per our hospital protocol. However, she had clinicoradiological worsening and required non-invasive ventilation (NIV) (pressure support—5 cm H2O, PEEP—12 and FiO2—80%). She also had features of the cytokine storm syndrome and was administered 2 doses of tocilizumab (8 mg/kg). On day 4th of hospitalization, she had sudden onset desaturation on NIV and hypotension. An emergency portable chest skiagram showed right-sided pneumothorax with pneumomediastinum. She was immediately managed with wide bore chest tube insertion on right side of chest with underwater seal. There was a gush of air in the seal signifying the presence of tension pneumothorax. However, she continued to deteriorate and later succumbed to her illness.

Fig. 1

Chest radiograph showing bilateral pneumothorax and pneumomediastinum.

COVID-19 is a disease caused by a novel coronavirus and since its onset in December 2019, it has caused havoc worldwide. It primarily affects the lungs, and chest radiology is an important tool in the diagnosis and prognostication. The usual presentation includes bilateral diffuse ground-glass opacities in the lower lobes, which are peripheral in distribution. There can also be features of consolidation, interlobular and intralobular septal thickening and bronchiectasis. The rare findings include pleural and pericardial effusion, lymphadenopathy and pneumothorax.,

Pneumothorax with pneumomediastinum in case of COVID-19 ARDS has rarely been reported.2, 3, 4, 5 The risk factor includes male gender, smoking, tall stature and even Valsalva manoeuvre like violent cough. The pathophysiology includes an increased pressure gradient between the alveoli and interstitium, which causes alveolar rupture and finally tracking of this air in between the venous sheaths to the mediastinum. The marked inflammation due to the release of various cytokines causes damage to airway epithelium and alveolar walls, which predisposes them to rupture. It is difficult to diagnose this entity in the ICU setting during the current COVID-19 pandemic, but any sudden desaturation with hypotension in these patients should raise a suspicion and warrants an emergency chest skiagram. The chest roentgenogram findings include continuous diaphragm sign, air around the great vessels and accentuation of cardiac borders. These patients should undergo urgent wide bore chest tube insertion along with oxygen and supportive therapy. It is difficult to obtain computerised tomogram in these patients as they are unstable with high oxygen demands. Spontaneous pneumothorax is an uncommon complication of COVID-19 ARDS and signifies poor prognosis.