1. Abstract A 39-year-old man presented to the emergency room with complaints of fever, shortness of breath and pronounced dry coughfor 1 week. On physical examination, his respiratory rate was 28 breaths/min and his oxygen saturation was 87 % on room air, improvingto96%on8L/minoxygenviaanon-rebreathingmask.He also had palpable crepitus around the neck and the upper thoracic region. Reverse transcription (RT)-PCR analysis of COVID-19 was positive. Chest computed tomography showed typical findings of COVID-19 pneumonia, affecting 60% of lungparenchyma. CTscanwasalsoremarkableforseverepneumomediastinumwith extensive subcutaneous emphysema extending into the neck, the thoraxandtheupperlimbs.Therewasnoevidenceofpneumothorax.An esophageal rupture was ruled out by esophagram. During thehospitalstay,hisrespiratorystatusprogressivelyimprovedand hisoxygenrequirementsgraduallydecreased,maintainingoxygen saturation > 96%. A repeat CT scan was performed at day 7 and showedsignificantregressionofthepneumomediastinum.Hewas discharged home on 13th day of admission.
Keywords: Pneumomediastinum; Emphysema; COVID-19
2. Introduction Since it’sdiscovery in late2019, Coronavirusdisease (COVID-19) has emerged worldwide and become a major global health problem.Itprimarilyinvolvestherespiratorysystem.Pneumomediastinum is a known complication in COVID 19 [1]. It is mostly observedinmechanicallyventilatedpatients[2].Herein,wereporta rare case of spontaneous pneumomediastinum with subcutaneous emphysema in a non-intubated COVID-19 patient.
3. Case Report A39-year-ol dman presented to the emergency department with complaintsoffever, myalgia, shortness of breath and pronounced dry cough for 1 week. He had no history of chronic obstructive pulmonary disease and asthma. He denied alcohol consumption and tobacco or drug use. On examination, he was conscious, febrile(temperature:38.4°C),withapulserateof105beats/minand bloodpressureof130/80mmHg.Respiratoryratewas26breaths/ min and oxygen saturation was 87 % on room air, improving to 95% on 8L/min oxygen via a non-rebreathing mask. He also had palpable crepitus around the neck and the upper thoracic region. Chest auscultation revealed bilateral rhonchi and fine crackles. Nasopharyngeal RT-PCR analysis was positive for SARS-CoV-2 infection.Bloodinvestigationsrevealedanormalwhitebloodcell count of 7.45 × 109 /L (normal range, 3.50–9.50 × 109 /L), elevatedbloodlevelsforC-reactiveprotein(76mg/L;normalrange, 0–10 mg/L) and normal kidney and liver tests. He was started on methylprednisolone, prophylactic enoxaparin and vitamins, and remained stable on non-invasive supplemental oxygen. Chest computed tomography showed typical findings of COVID-19 pneumonia,affecting60%oflungparenchyma.CTscanwasalso remarkableforseverepneumomediastinumwithextensivesubcutaneous emphysema extending into the neck, the thorax and the upper limbs.There was no evidence of pneumothorax (Figure 1). An esophageal rupture was ruled out by esophagram.As the vital signs were stable, the patient was treated conservatively. During thehospitalstay,hisrespiratorystatusprogressivelyimprovedand hisoxygenrequirementsgraduallydecreased,maintainingoxygen saturation > 96%. A repeat CT scan was performed at day 7 and showedsignificantregressionofthepneumomediastinum(Figure 2). He was discharged home on 13th day of admission.
4. Discussion Spontaneous pneumomediastinum (SPM) is an uncommon clinicaloccurrencewhichisusuallycausedbymedicalconditionssuch as chronic obstructive pulmonary disease, asthma and pulmonary infections [3]. It has been reported as single cases in COVID-19 patients since the pandemic started [4]. While most of the cases were managed conservatively, it can be life-threatening and does requireclosemonitoring[5,6].TheunderlyingmechanismofSPM in COVID-19 patients may relate to increased alveolar pressure andextensivealveolarmembranedamagecausingalveolarrupture [7]. This rupture might lead to air dissection along the bronchovascular sheaths, causing pulmonary interstitial emphysema that spreads toward the mediastinum [8].Although our patient had no historyofchroniclungdiseaseandhadneverrequiredmechanical ventilation during his hospital stay, his pronounced cough would have been a major factor in the occurrence of SPM. Through this case,weaimtohighlightthatpneumomediastinuminCOVID-19 patients could be a possible indicator of worsening disease and should be monitored carefully, although our patient had a favorable course.
References 1. Palumbo D, Campochiaro C, Belletti A, Marinosci A, Dagna L,Zangrillo E, et al. Pneumothorax/pneumomediastinum in nonin-tubated COVID-19 patients: differences between first and secondItalian pandemic wave. Eur J Intern Med. 2021; 88: 144-6.
2. Belletti A, Palumbo D, Zangrillo A, Fominskiy EV, Franchini S,Dell’AcquaA,etal.Predictorsofpneumothorax/pneumomediastinum in mechanically ventilated COVID-19 patients. J Cardiothorac Vasc Anesth. 2021; 35(12): 3642-51.
3. SahniS,VermaS,GrullonJ,EsquireA,PatelP,TalwarA.Sponta-neous pneumomediastinum: time for consensus. NorthAm J MedSci. 2013; 5: 460.
4. Mohan V, Tauseen RA. Spontaneous pneumomediastinum inCOVID-19. BMJ Case Rep CP. 2020; 13: e236519.
5. Kangas-DickA, Gazivoda V, Ibrahim M, SunA, Shaw JP, BrichkovI,etal.ClinicalcharacteristicsandoutcomeofpneumomediastinuminpatientswithCOVID19pneumonia.JLaparoendoscAdvSurg Tech. 2021; 31: 273–278.
6. Wang J, Su X, Zhang T, et al. Spontaneous pneumomediastinum:a probable unusual complication of coronavirus disease 2019(COVID-19) pneumonia. Korean J Radiol. 2020; 21: 627.
7. Lei P, Mao J, Wang P. Spontaneous pneumomediastinum in a patient with coronavirus disease 2019 pneumonia and the possibleunderlying mechanism. Korean J Radiol. 2020; 21: 929.
8. Machiraju PK, Alex NM, Safinaaz, Baby NM. PneumomediastinuminCOVID19:Aseriesofthreecasesandreviewofliterature.SAGE Open Med Case Rep. 2021; 9: 2050313X211011807.
Mohamed Hajri. Spontaneous Pneumomediastinum with Subcutaneous Emphysemaina COVID-19 Patient. Annals of Clinical and Medical Case Reports 2022