Pneumomediastinum in COVID-19: A series of three cases and review of literature

Abstract

Coronavirus disease-19 caused by severe acute respiratory syndrome Corona virus-2 is characterised by wide heterogeneity in clinical presentation. The typical radiographic findings in COVID-19 include bilateral ground-glass opacities and/or consolidations predominantly affecting the lower lobes and posterior segments of lungs. Other rare abnormal radiographic findings include pneumothorax, pneumomediastinum and pneumopericardium. There has been an increased incidence of pneumomediastinum, a rare but potentially life-threatening complication during this pandemic. It may be spontaneous or secondary. Pneumomediastinum may be due to barotrauma, cytokine storm induced diffuse alveolar injury or direct viral infection of type I and type II pneumocytes. The presence of pneumomediastinum in COVID-19 patients may indicate extensive alveolar membrane destruction and those patients need close monitoring. There are no consensus guidelines in managing COVID-19 patients with pneumomediastinum. Higher mortality rates (70.58%) are reported in intubated COVID-19 patients with pneumomediastinum. The development of pneumomediastinum in COVID-19 should be considered as a poor prognostic factor.

Pneumomediastinum: Radiological profile and associations of uncommon complication of COVID-19

“…However, spontaneous pneumomediastinum in the absence of mechanical ventilation or other lung diseases in the COVID-19 patients is explained by the Macklin Effect which ascertains that the alveolar damage caused by infiltration of both Types I and II pneumocytes leads to the leak of air along the vascular sheaths in the interstitium which further circulates into the mediastinum. [ 8 9 10 11 ] In patients with COVID-19-associated pneumonitis, spontaneous pneumomediastinum is seen in around 10% of the hospitalized patients in various studies similar to our observation of an incidence of 8.75%. [ 4 10 12 ]…”

“…[ 8 9 10 11 ] In patients with COVID-19-associated pneumonitis, spontaneous pneumomediastinum is seen in around 10% of the hospitalized patients in various studies similar to our observation of an incidence of 8.75%. [ 4 10 12 ]…”

A Rare Complication of Pneumopericardium, Spontaneous Pneumothorax, and Subcutaneous Emphysema in a COVID-19 Pneumonia Patient Treated With High Flow Nasal Cannula

“…Third is the prothrombotic effect of COVID-19 infection-causing pulmonary vascular thrombosis and subsequent necrosis in the alveolar membranes. Fourth is cytokine storm-induced diffuse alveolar injury or direct viral infection of type 1 and type 2 pneumocytes increasing the risk of alveolar rupture [ 3 ].…”

“…SPM is associated with other medical conditions, including asthma, connective tissue disease, interstitial lung disease, diabetic ketoacidosis, chronic obstructive airway disease, and influenza-like syndrome. [ 1 ] SPM is reported to develop in 10% of cases of intubated COVID-19 with acute respiratory distress syndrome (ARDS) even with low tidal volume strategies [ 2 , 3 ]. One unmatched case control study of 271 patients showed the incidence of SPM among non-intubated acute COVID-19 patients at 3.3%, similar to our patient [ 4 ].…”

Tracheal Diverticulum in SARS-CoV-2 Patients on Non-Invasive Ventilation A not so “Spontaneous” Cause of Pneumomediastinum? An imaging Pictorial Presentation of Two Cases with Review of Literature

“…This effect states that the inciting event leading to spontaneous pneumomediastinum is alveolar injury, which in turn causes interstitial emphysema and air tracking along the peribronchovascular interstitium. The cause of alveolar injury can be barotrauma, cytokine storm leading to diffuse alveolar injury or direct infection of pneumocytes with the virus [ 3 ]. Most of the patients with severe pneumonia complicated with hypoxemic respiratory failure goes on to require some form of positive pressure ventilatory support.…”