Case Report: Massive Spontaneous Pneumothorax—A Rare Form of Presentation for Severe COVID-19 Pneumonia

Abstract

Background and Objectives: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a viral disease that is spreading worldwide and became a pandemic. Although most of the time, the symptoms of the infection are flu like, a percentage of patients develop severe forms, along with severe complications. Many of them are known among front-line health workers, but the number of uncommon presentations and complications has increased. This case report aims to alert healthcare workers on less common forms of presentation, and to introduce this differential diagnosis in the evaluation of patients with COVID-19, given the increasing occurrence of pneumothorax in patients who are not mechanical ventilated. Case presentation: A 57-year-old female patient came to the Emergency Department (ED) by ambulance, with acute respiratory failure. She had SpO2 = 43% on room air at home, and 86% on admission in ED after oxygen delivery (on a reservoir mask). SARS-CoV-2 infection was suspected based on symptoms that started three days ago (fever, dry cough, dyspnea, and fatigability). Blood was taken for lab tests, pharyngeal and nasal swabs for the reverse transcription–PCR (RT-PCR) test, and native computed tomography (CT) was scheduled. The thoracic CT scan showed massive right pneumothorax, partially collapsed lung, multiple bilateral lung infiltrates with a ground glass aspect and the RT-PCR test came back positive for SARS-CoV-2 infection. Despite the prompt diagnosis and treatment of pneumothorax (thoracostomy was performed and the drain tube was placed), the patient died after a long hospitalization in the intensive care unit. Conclusion: Secondary spontaneous pneumothorax (SSP), as a complication in severe forms of COVID-19 pneumonia, especially in female patients without risk factors is rare, and early diagnosis and treatment are essential for increasing the survival chances of these patients.

Risk Factors, Characteristics, and Outcome in Non-Ventilated Patients with Spontaneous Pneumothorax or Pneumomediastinum Associated with SARS-CoV-2 Infection

“…Its prevalence, risk factors, and final outcome remain unclear. 13,14,[30][31][32][33][34][36][37][38][39] Our research contributes to understanding the combination of SP, SPM and COVID-19 in non-ventilated patients, and quantifying their associated risks for in-hospital mortality.…”

“…6,8,11 It correlated with the severity of lung damage, rather than with the magnitude of SP-SPM. [12][13][14] However, a multicenter retrospective case study by Martinelli et al 7 challenged these findings, reporting an overall survival rate of 63.1% in patients confirmed with COVID-19 and SP. 7 We conducted a one-year review of the medical records in the emergency departments (ED) of two tertiary hospitals: Emergency Clinical Municipal Hospital and "Pius Brinzeu" Emergency Clinical County Hospital, both teaching hospitals affiliated with Victor Babes University of Medicine and Pharmacy in Timisoara.…”

Secondary Spontaneous Pneumothorax in a COVID-19 Recovered Patient

“…There are increased reports of spontaneous pneumothorax in patients within the literature, which were thought to be an uncommon sequela of the infection. However, the development of the complication is not well understood, with some sources citing the virus as the cause while others are implicating pneumonia, poor intubation technique, or barotrauma [4][5][6][7]. In cases without proof of barotrauma, a secondary spontaneous pneumothorax may develop in the context of COVID-19 in 1% of patients [8].…”

Primary spontaneous partial pneumothorax in a patient with COVID-19 pneumonia. Have We underestimated this complication?: A case report

“…PSP is frequent in young people, with men having a higher frequency than women (7.4-18 per 100.000 men and 1.2-6 per 100.000 women). Being a male, having a slim and tall stature, and smoking are all risk factors (5). Some studies observed that PSP in COVID-19 pneumonia is usually associated with hypertension (37.5%), asthma (20%), and diabetes (17.5%), none of which were present in our patient (6).…”