BACKGROUND Spontaneous pneumomediastinum (SPM) is more common in young adults, usually caused by external factors like trauma. It causes symptoms such as chest pain or dyspnea, but it is rare to see elderly patients who develop SPM. Here we report the case of an elderly patient diagnosed with coronavirus disease 2019 (COVID-19) who neither got mechanical ventilation nor had chest trauma but were found to develop SPM for unknown reason. CASE SUMMARY A 62-year-old man complained of a 14-d history of fever accompanied by dry cough, shortness of breath, wheezing, myalgia, nausea, and vomiting. Real-time fluorescence polymerase chain reaction confirmed the diagnosis of COVID-19. The patient was treated with supplementary oxygen by nasal cannula and gamma globulin. Other symptomatic treatments included antibacterial and antiviral treatments. On day 4 of hospitalization, he reported sudden onset of dyspnea. On day 6, he was somnolent. On day 12, the patient reported worsening right-sided chest pain which eventually progressed to bilateral chest pain. He was diagnosed with SPM, with no clear trigger found. Conservative treatment was administrated. During follow-up, the pneumomediastinum had resolved and the patient recovered without other complications. CONCLUSION We presume that aging lung changes and bronchopulmonary infection play an important part in the onset of SPM in COVID-19, but severe acute respiratory syndrome may represent a separate pathophysiologic mechanism for pneumomediastinum. Although the incidence of SPM in elderly patients is low, clinicians should be alert to the possibility of SPM in those infected with severe acute respiratory syndrome coronavirus 2 for life-threatening complications such as cardiorespiratory arrest may occur.

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