Kevin O. Wortman1, Kevin O. Wortman2
Volume 9, Number 3: 223-226
Received 19 04 2021: Rev-request 01 05 2021: Rev-request 30 07 2021: Rev-recd 07 05 2021: Rev-recd 07 08 2021: Accepted 11 08 2021: Publication 24 08 2021
The COVID-19 pandemic has been challenging medical professionals and facilities for over a year now. Much of the literature describes pathologic lung changes and complications associated with SARS-CoV-2, with pneumothorax and pneumatoceles not being uncommon.The Case:
We describe a case involving a patient that presented to the emergency department with a pneumothorax. Three weeks prior, the patient was hospitalized for 10 days in acute respiratory distress secondary to SARS-CoV-2 pneumonia, which did not require ventilator support. Follow up imaging revealed a 7 cm (AP) × 4.6 cm (transverse) × 2.5 (cc) cm pneumatocele.Conclusion:
We speculate that antecedent rupture of an unrecognized pneumatocele likely caused lung collapse leading to the patient's pneumothorax. This review delves into the etiology of both pneumothoraxes and pneumatoceles along with their relation to SARS-CoV-2 pneumonia.
Keywords: COVID-19; Pneumatocele; Pneumothorax; Tension Pneumothorax; SARS-CoV-2 (Source: MeSH-NLM).
This article describes the clinical course of a patient that presented to an Emergency Department (ED) with a spontaneous pneumothorax post-SARS-CoV-2 pneumonia, with a pneumatocele discovered on radiography. While pneumatoceles are more common within the post-pneumonia, pediatric population,1 a retrospective study has shown pneumatocele development as a missed diagnosis in up to 37% of their 78 patients with the coronavirus disease.2 Additional studies show varying numbers with pneumatocele development seen in 10% of 81 symptomatic patients in the study by Shi et al.3 and in 5.3% of 57 SARSCoV-2 positive patients in the study Qi et al.4 Radiologic studies use terms such as ‘cystic air spaces,’2 ‘cystic changes,’3 and ‘emphysema,’4 which are synonymous with pneumatocele. Pneumatoceles, in relation to COVID-19, are highly variable in size; some are categorized as ‘giant bullae’5 and typically present in multiples rather than a singular lesion.6
A predictable complication of pneumatoceles is pneumothorax.1,5 A few case studies report pneumothoraxes as a rare complication of COVID-19.7,8 Risk factors for pneumothorax include young age, chest trauma,1 individuals with imaging demonstrating fibrotic lung changes,9 individuals with a more severe clinical course, prolonged pneumonitis duration, and higher neutrophil counts.10 In our experience with COVID-19 management, pneumothorax is more common in mechanically ventilated patients, which is as high as 13% in one study,11 likely due to barotrauma. However, patients are presenting with pneumothoraxes well before ventilatory support is provided.
A 28-year-old African American male presented to an ED reporting chest and back pressure/pain along with shortness of breath. Three weeks prior, the patient presented to the same ED in respiratory distress secondary to PCR confirmed SARS-CoV-2 pneumonia. He was hospitalized for 10 days and received oxygen, remdesivir, dexamethasone, tocilizumab, and enoxaparin therapy. The patient did not require mechanical ventilation during his prior hospitalization.
- COVID-19 recovery complications are not emphasized in literature as much as pathophysiology, clinical treatment, and epidemiology.
- As the pandemic is taking its course, many patients are recovering from COVID-19 but may be at risk for complications.
- To ensure pneumatoceles are diagnosed and tracked in anticipation of spontaneous pneumothorax, we recommend that patients post-COVID-19 pneumonitis are assessed radiographically before hospital discharge and within two weeks after discharge. This will lead to early detection of pneumatoceles and will provide an insight into a subgroup of COVID-19 patients that may be at risk for multiple pathological pulmonary events after COVID-19 hospitalization. This will aid physicians in being cognizant regarding this subgroup of patients who will benefit from a more stringent monitoring.
- Larger studies are warranted to distinguish between Long COVID/Long-haul COVID/Post-acute sequelae SARS-CoV-2 (PASC) and Post-COVID-19 pneumonitis as well as the complications related to both these conditions.
During the current presentation to the ED for respiratory distress the patient was saturating at 82% on room air, which improved to 92% on 4 liters per minute of nasal cannula oxygen. Chest radiographs revealed a large right pneumothorax with subsequent mediastinal shift to the left (Figure 1). A pigtail catheter was inserted at the 2nd intercostal space along the midclavicular line.Figure 1.
(A): Patient's chest x-ray taken during the previous hospitalization, showing extensive bilateral interstitial airspace opacities throughout the right and left lungs. (B): Patient's chest x-ray at presentation showing a large right pneumothorax, with the majority of the right lung collapsed. There is mild to moderate mediastinal shift to the left. Both lungs show evidence of bilateral airspace/interstitial disease.
After two days, the catheter accidentally dislodged from the patient's pleural space and serial CXRs were performed to determine whether the pneumothorax had resolved. Although the patient was clinically asymptomatic, the radiographs showed worsening of the pneumothorax; therefore, a pigtail catheter was reinserted at the 4th intercostal space along the mid axillary line. The CXR on Day 4 also showed formation of a round lesion with central air-fluid levels that was speculated to be a pneumatocele (Figure 2). On subsequent imaging, the pneumothorax appears to have improved, although not completely resolved (Figure 3). The lesion was monitored by a local pulmonologist and treated daily with fluticasone inhaled therapy, until resolution 7 weeks later.Figure 2.
Follow up chest x-ray on Day 4 showing an unresolved right pneumothorax (20-30%) and ill-defined pulmonary opacities throughout both lungs, deduced to be bilateral interstitial disease. A round lesion with central air-fluid levels formed within the right mid lung and was speculated to be a pneumatocele
Non-contrast CT scans showing resolution of the pneumothorax. Laterally in right upper lobe, there is oval-shaped lucent lesion measuring 7 cm (AP) × 4.6 cm (transverse) × 2.5 cm (cc). Wall is thin and barely perceptible. Inner margin of the cavity is smooth. There is an internal air-fluid level. It is difficult to tell if this collection is tracking along the minor fissure. Numerous scattered ground-glass pulmonary opacities are present throughout each lung.
Textbook pneumothorax patients often have a history of a connective tissue disorder, such as Marfan syndrome or Ehlers-Danlos syndrome, and/or have a characteristic marfanoid habitus, COPD, smoking, or pregnancy.12 Our patient denied a recent history of trauma, denied a history of smoking, and had a body mass index of 35.9 kg/m2. This patient does not fit into the standard demographic of patients at an increased risk of pneumothorax and there are still uncertainties regarding COVID-19-related lung changes and complications. This led us to hypothesize that pneumatoceles may well be a potential mechanism behind this pneumothorax.
The percentage of COVID-19 cases that are complicated by pneumatocele development has yet to be determined. Pneumatoceles typically appear 5-6 days after the infectious process secondary to SARS-CoV-2.13 However, spontaneous pneumothorax is a known, rare complication of COVID-19 and can occur in the absence of mechanical ventilation,14 with studies showing that pneumothorax occurs within a window of 14–37 days after hospitalization.7 Pneumothorax is also not a common sequel to pneumatoceles as the majority of pneumatoceles resolve spontaneously within a few weeks to a year, without intervention.1 In this case, while no pneumatocele was identified before or at presentation, antecedent rupture of an unacknowledged pneumatocele could have led to the pneumothorax. The single pneumatocele lesion likely formed due to parenchymal inflammation secondary to acute respiratory distress syndrome (ARDS), which is not uncommon.15 There have not been any studies that deduce a specific mechanism for COVID-19 infection itself eliciting pneumatocele formation, without pneumonitis underplay.
Pneumothoraxes are rarely fatal; however, they have recurrence rate of up to 32% within 12 months according to one meta-analysis.16 This patient's pneumothorax pathology could have occurred either through pneumatocele rupture, which has been reported in other case studies,8 or due to COVID-19-induced pulmonary parenchymal injury and necrosis with development of air leaks into the pleural cavity. While the former has not been thoroughly studied due to the relative novelty of COVID-19, the latter was noted previously during the SARS outbreak.16,17 If pulmonary necrosis led to pneumothorax, then the pneumatocele seen in this patient was likely an incidental finding.
As per the World Health Organization (WHO), most COVID-19 patients experience a mild-to-moderate clinical course, with 10-15% of patients progressing to a severe clinical presentation and 5% progressing to critical illness. In general, recovery can take anywhere from 2–6 weeks, depending on the severity of the case. Unfortunately, some patients experience symptoms for weeks to months, regardless of disease severity.18 These patients were colloquially deemed ‘long COVID’ or ‘COVID long-haulers,’ which later became ‘post-acute sequelae of SARSCoV-2 (PASC)’. Studies suggest that roughly one-third of those infected with SARS-CoV-2, whether asymptomatic during infection or not, may develop PASC.19,20 According to a study conducted by Lambert et al.21, of the 5,875 COVID-19 survivors surveyed, 5,163 reported symptoms persisting longer than 21 days. The most common symptom reported was fatigue (79.0%) and followed by headache/migraines (55.3%), shortness of breath (55.3%), difficulty concentrating (53.6%), cough (49.0%), changed sense of taste (44.9%), diarrhea (43.9%), muscle/body aches (43.5%), and heart palpitations (39.5%).21 Another study surveying 3,762 respondents from 56 countries reported the most frequent symptoms being fatigue (77.7%), post-exertional malaise (72.2%), and cognitive dysfunction (55.4%).22 Risk factors for PASC include hypertension, obesity, prior mental health conditions,21 and female gender (two times increased risk as compared to males).23 While COVID-19 is at the forefront of research, a clear distinction must be made between individuals suffering from PASC and post-COVID-19 pneumonitis, as well as their respective complications. Larger retrospective cohort studies and case reports, pertaining to both PASC and Post-COVID-19 pneumonitis, are warranted.
Cystic lesions, pneumatoceles, and subsequently pneumothoraxes are likely to result from prolonged SARS-CoV-2 pneumonia causing air leaks. This is similar to the clinical course observed in patients with SARS, caused by a virus within the same Coronaviridae family, during the 2003 outbreak. To ensure pneumatoceles are diagnosed and tracked in anticipation of spontaneous pneumothorax, we recommend that patients with post-COVID-19 pneumonitis, especially those given ventilator support, are assessed radiographically before hospital discharge and within two weeks after discharge. This will lead to early detection of pneumatoceles and will provide an insight into a sub-group of COVID-19 patients that may be at risk for multiple pathological pulmonary events after COVID-19 hospitalization. This could physicians in being cognizant regarding this sub-group of patients, who could benefit from more stringent monitoring. Furthermore, larger studies are warranted to distinguish between Long COVID/Long-haul COVID/Post-acute sequelae SARS-CoV-2 (PASC) and Post-COVID-19 pneumonitis, as well as the complications related to both these conditions.
The Authors have no funding, financial relationships or conflicts of interest to disclose.
Conceptualization, Investigation, Resources: KOW II & KOW Sr. Data Curation, Project Administration, Supervision, Writing – Original Draft Preparation: KOW II. Writing – Review & Editing: KOW Sr.
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Kevin O. Wortman, 1 M.S., Edward via College of Medicine, Auburn, Alabama, United States
Kevin O. Wortman, 2 R.N. BSN CCRN.
About the Author: Kevin Wortman II is currently a 4th year osteopathic medical student of Edward via COM- Auburn, AL USA; which is a 4-year program. He is also the recipient of the 2019 Sherry Arnstein Minority Student scholarship, funded by the American Association of Colleges of Osteopathic Medicine, and 2020 J. W. Darden scholarship, funded by the J. W. Darden Foundation.
Correspondence: Kevin O. Wortman II. Address: 910 S Donahue Dr, Auburn, AL 36832, United States. Email: Kwortman@auburn.vcom.edu
Editor: Mihnea-Alexandru Găman Student Editor: Najdat Bazarbashi Copyeditor: Joseph Tonge & Ciara Egan Proofreader: Ciara Egan Layout Editor: Francisco J. Bonilla-Escobar Process: Peer-reviewed
Cite as: Wortman II KO, Wortman Sr KO. Pneumatocele-Induced Pneumothorax in a Patient with Post-COVID-19 Pneumonitis. A Case Report. Int J Med Students. 2021 Jul-Sep;9(3):223-6.
Copyright © 2021 Kevin O. Wortman II, Kevin O. Wortman Sr.
This work is licensed under a Creative Commons Attribution 4.0 International License.
International Journal of Medical Students, VOLUME 9, NUMBER 3, September 2021