1. Abstract Spontaneous pneumothorax associated with COVID-19 is rare. We reported four cases and reviewed the literature. Among the reports, 29% and 42% were a-/oligosymptomatic or symptomatic butimproving, respectively. Clinici an smustbea ware of this complication because it can happen when the patient with COVID-19 was a-/oligosymptomatic or had improving symptoms
Keywords: COVID-19; Spont aneouspneu mothorax; Respiratory failure
1. Introduction Pneumothorax is the presence of air in the pleural space due to communications between the pleural and the alveolar/external spaces or the presence of gas-producing organisms in the pleural space. Spontaneous pneumothorax (SP) is diagnosed when no injuryhasbeeninflictedtothethorax.TherearetwotypesofSP:primarySP,withoutapparentunderlyinglungdisease,andsecondary SP, when there is a clinically apparent disease. SPis a rare event amongpeoplewithsevereacuterespiratorysyndromecoronavirus 2 (SARS-CoV-2) pneumonia or COVID-19.1 We described four cases of COVID-19-associated SP in patients treated at our hospital
2. Case Reports The study was approved by the Committeeon Ethicson Research of the Hospital Eduardo de Menezes. Between March/1/2020- June/30/2021, we prospectively searched all patients hospitalized because of SP during or after COVID-19. The enrolled patients signed theCon sent Form. COVID-19 was diagnosed by reverse transcriptase polymerase chain reaction for SARS-CoV-2 from nasopharyngeal swab. We defined SP as pneumothorax detected by any imagemodality with out previous positive-pressur event ilation, neck/chestmanipulation, ortrauma. Wecollected datausing a standardized form.
Case 1 An84-year-old man with motorsequelae of stroke, hyperlipidem- ia, mood disorder, benign prostatic disease, and previous smoker presented to the Emergency Department (ED) with one-day fever, cough, anddyspnea. Hewasafebrile, tachypneic with mildbreath- ing effort, normal lung sounds, and desaturating. He was dis- charged home three days before, after a two-week hospitalization duetoCOVID-19andcomplainingfever,drycough,anddiarrhea. During this hospitalization, his chest computed tomography (CT) evidenced ground-glass opacities in 50% of the lung parenchyma (Figure 1A). He received oxygen by nasal cannula, dexamethasone, amoxycillin+clavulanate, azithromycin, and enoxaparin. Upon his return, he had elevated reactive C-protein (RCP). Other laboratory tests were unremarkable.The new chest CTevidenced sparse ground-glass opacities, and a small left-sided pneumothorax with bilateral small pleural effusion (Figure 1B). He received oxygen by nasal cannula, and dexamethasone was reintroduced. He received piperacillin+tazobactam and thromboprophylaxis. Pneumothorax was treated conservatively. He was discharged home after one week.
Case 2 A77-year-old man with dementia and strokesequelaepresentedto the ED with COVID-19 after one day of agitation, with out cough. Hestopped smoking for approximately 30years. He was afebrile, with normal lung sounds, tachypneic and desaturating, tachycar- dic, and mildly hypertensive. He had leucocytosis, with elevated RCP, lacticacid, andlactic-dehydrogenase. Otherlaboratorytests wereunremarkable. Ground-glassopacitiescoveredlessthan25% ofthelungparenchyma,withalargeright-sidedpneumothoraxand collapse of the right lung (Figure 2A).Achest drain was inserted withawater-seal.Hereceivedoxygenbyfacemask,amoxycillin+- clavulanate, azithromycin, dexamethasone, and enoxaparin. Clinical conditions improved and the follow-up chest CT confirmed lungexpansion,withright-sidedpleuraleffusionandbilateralconsolidations (Figure 2B). The drain was removed three days after insertion.Oneweekafterhospitalization,hisrespiratorycondition worsened.HewasfebrilewithleucocytosisandincreasedRCP.A newchestCTevidencedsparseground-glassopacities,butalarg- er pleural effusion associated with pleural thickness (Figure 2C). Pleuraldecorticationwasperformed,andpiperacillin+tazobactam andteicoplaninwereprescribed.Vancomycinwasprescribed,due to Staphylococcus haemoliticus vancomycin-sensitive on a cathetertipculture.Fluconazolewasassociated,duetoskincandidiasis on seborrheic dermatitis. Since fever was recurrent and he started diarrhea,anewcourseofpiperacillin+tazobactamwithmetronidazolewasinitiated,withSaccharomycesboulardiiandracecadotril. Clostridiumdificileglutamatedehydrogenasewasnegative.Klebsiellapneumoniaessp.pneumoniaeandPseudomonasaeruginosa amikacin-sensitive were identified on the culture of his calcaneus tissue injury, and he received amikacin. He was discharged home after 86 days of hospitalization.
Case 3 A67-year-old woman presented to the ED complaining fever, confusion, dizziness, drycough, and tachypnea, inthelast sevendays. She had lung emphysema due to previous smoking with oxygen supplementation at least three-quarters of the daytime. She was treating systemic arterial hypertension, dyslipidemia, hypovitaminosis D, and hypothyroidism. She also had a hearing sequela due to previous stroke. She had mild COVID-19 two months before.Shewasafebrile,dyspneicwithmoderateeffort,desaturating atroomair,andhypertensive.Laboratorytestswereunremarkable. SARS-CoV-2wasnotdetected.ChestCTevidencedacentrolobularemphysemaandalargeleftpneumothoraxwithamildright-deviated mediastinum (Figure 3). Low-flow oxygen was provided, and she received azithromycin and piperacillin+tazobactam, corticosteroids,bronchodilators,codeine,andthromboprophylaxis.A chest drain was inserted, connected to a water-seal. Bullectomy and pleurodesis were performed 5 days after tube insertion, becauseofahigh-flowairdrainage.Chesttubewasremoved5days later. She was discharged home after 14 days of hospitalization.
Case 4 A previously healthy 22-year-old man with COVID-19 was admittedafteroneweekofsorethroatanddrycough.Atadmission, he was dyspneic with moderate effort, desaturating, tachycardic, andnormotensive.Hedeniedsmoking.HehadelevatedRCP.The other blood tests were unremarkable. Chest CT showed groundglass opacities covering more than 50% of the lung parenchyma and few consolidation foci (Figure 4A). A mild-to-moderate bilateralpneumothoraxassociatedwithpneumomediastinumand pneumopericardium was also noted. Oxygen was offered by face mask. He received dexamethasone, thromboprophylaxis, and amoxycillin+clavulanate and azithromycin. His respiratory effort worsened, and he was intubated and mechanically ventilated in proneposition.Twochesttubeswereinsertedinbothhisrightand left hemithoraces, all connected to water-seals. Chest tubes were withdrawn after four days. He self-extubated three days later. He was discharged home, with a normal chest CT and breathing at room air (Figure 4B).
3. Discussion Since the beginning of the pandemic, many cases of COVID-19 associated SP were reported. SARS-CoV 2 causes a diffuse alveolar damage with perivascular immune cell infiltration, severe end othelialinjury, and wide spread thrombosis, whichmay lead to air leak and dilatation of some alveoli and hemorrhagic/ edematous collapse of others. 2 The final rupture of the alveolar wallisaconse quence of ashearstress (e.g.,coughing), developing a communication with the pleural space. Ultimately, COVID-19 may also be considered a cause of SP. However, it should be highlighted it is an unusual complication of COVID-19 (relative frequency of 0.57‰), although more common in affected than in non-affected individuals.1, 2 Arecentcase -controlstudydescribed 40 COVID -19-associated SP (i.e., without previous positive -pressureventilation, chestmani pulation or trauma) among71, 904 patients attending in 50 Spanish EDs.3 Patients with COVID-19 who developed SP more frequently were men and their median agesimilartooursearch. 3Theyalsomorefrequentlyhaddyspnea/ tachypnea and chest pain, desaturation, and increased leukocyte count, than those without COVID -19. 3 Another registry held in16 centers in the United Kingdom which reported 20 patientswith COVID -19 -associated SP. 4 Nine patients had the diagnosis of pneumothorax at presentation to the ED, from which fivewere readmissions. 4 All cases we described had the diagnosis of pneumothoraxatadmission,afterimprovingorcomplainingmild symptoms.
4. Conclusion COVID-19 -associated SP is a potentially severe, although rare, complication. Physicians should be aware of this important pneu matosis because it can happenin people with out previousdiag.
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2. Menter T, Haslbauer JD, Nienhold R. Postmortem examination of COVID -19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction. Histopathology. 2020; 77(2):198 -209.
3. Miro O, Llorens P, Jiménez S. Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019:ACase Control, Emergency Medicine -Based Multicenter Study. Chest. 2021; 159(3): 1241255.
4. Martinelli AW, Ingle T, Newman J. COVID-19 and pneumothorax: A multicentre retrospective case series. Eur Respir J. 2020; 56(5):2002697.
Ricardo Mesquita Camelo. COVID-19-Associated Pneumothorax: Case Reports. Annals of Clinical and Medical Case Reports 2022