COVID-19 the Lung Popper!

Introduction COVID-19 can result in multiple complications including thrombo-embolism, ARDS and septic shock. A rare complication is Spontaneous pneumomediastinum(SPM), pneumothorax(PNX) and subcutaneous emphysema(SCE) unrelated to positive-pressure ventilators. Such patients have a potential for a worse outcome. Case Description A 63-year-old male, non-smoker, with PMH of hypertension and diabetes-mellitus presented with worsening SOB and fever after testing positive for COVID-19. He denied cough, chest pain or vomiting. On exam he was calm with oxygen-saturation of 96% on non-rebreather, and had bilateral pulmonary rhonchi. Labs showed elevated inflammatory markers with significant LDH of 804units/L. Initial CT-chest showed extensive bilateral infiltrates. He completed antibiotics, antiviral and continued on steroids. He remained on supplemental oxygen and never required a positive-pressure oxygen device. On day-13, he decompensated. Repeat CT-chest showed extensive SCE and SPM compressing the anterior heart with biapical PNX. He responded well to conservative management and his oxygen requirements decreased. Follow up CT-chest in a month showed significant improvement of the SPM and resolution of the PNX and SCE. Discussion Macklin describes the pathophysiology behind SPM, which involves alveolar rupture leading to air leak through the broncho-vascular sheath to the mediastinum. Studies suggest that the cytokine storm in COVID-19 can result in diffuse alveolar injury. This will prone the alveolar wall to rupture. High LDH, which signifies cellular damage, was associated with SPM in SARS-CoV. Most cases in the literature show spontaneous resolution with conservative management including mitigation of reasons that increase alveolar pressure. A sudden worsening outcome should prompt an early CT-chest.