COVID-19-Associated Pneumothorax: Case Reports

1. Abstract Spontaneous pneumothorax associated with COVID-19 is rare. We reported four cases and reviewed the literature. Among the reports, 29% and 42% were a-/oligosymptomatic or symptomatic butimproving, respectively. Clinici an smustbea ware of this complication because it can happen when the patient with COVID-19 was a-/oligosymptomatic or had improving symptoms

Keywords: COVID-19; Spont aneouspneu mothorax; Respiratory failure

1. Introduction Pneumothorax is the presence of air in the pleural space due to communications between the pleural and the alveolar/external spaces or the presence of gas-producing organisms in the pleural space. Spontaneous pneumothorax (SP) is diagnosed when no injuryhasbeeninflictedtothethorax.TherearetwotypesofSP:primarySP,withoutapparentunderlyinglungdisease,andsecondary SP, when there is a clinically apparent disease. SPis a rare event amongpeoplewithsevereacuterespiratorysyndromecoronavirus 2 (SARS-CoV-2) pneumonia or COVID-19.1 We described four cases of COVID-19-associated SP in patients treated at our hospital

2. Case Reports The study was approved by the Committeeon Ethicson Research of the Hospital Eduardo de Menezes. Between March/1/2020- June/30/2021, we prospectively searched all patients hospitalized because of SP during or after COVID-19. The enrolled patients signed theCon sent Form. COVID-19 was diagnosed by reverse transcriptase polymerase chain reaction for SARS-CoV-2 from nasopharyngeal swab. We defined SP as pneumothorax detected by any imagemodality with out previous positive-pressur event ilation, neck/chestmanipulation, ortrauma. Wecollected datausing a standardized form.

Case 1 An84-year-old man with motorsequelae of stroke, hyperlipidem- ia, mood disorder, benign prostatic disease, and previous smoker presented to the Emergency Department (ED) with one-day fever, cough, anddyspnea. Hewasafebrile, tachypneic with mildbreath- ing effort, normal lung sounds, and desaturating. He was dis- charged home three days before, after a two-week hospitalization duetoCOVID-19andcomplainingfever,drycough,anddiarrhea. During this hospitalization, his chest computed tomography (CT) evidenced ground-glass opacities in 50% of the lung parenchyma (Figure 1A). He received oxygen by nasal cannula, dexamethasone, amoxycillin+clavulanate, azithromycin, and enoxaparin. Upon his return, he had elevated reactive C-protein (RCP). Other laboratory tests were unremarkable.The new chest CTevidenced sparse ground-glass opacities, and a small left-sided pneumothorax with bilateral small pleural effusion (Figure 1B). He received oxygen by nasal cannula, and dexamethasone was reintroduced. He received piperacillin+tazobactam and thromboprophylaxis. Pneumothorax was treated conservatively. He was discharged home after one week.

Case 2 A77-year-old man with dementia and strokesequelaepresentedto the ED with COVID-19 after one day of agitation, with out cough. Hestopped smoking for approximately 30years. He was afebrile, with normal lung sounds, tachypneic and desaturating, tachycar- dic, and mildly hypertensive. He had leucocytosis, with elevated RCP, lacticacid, andlactic-dehydrogenase. Otherlaboratorytests wereunremarkable. Ground-glassopacitiescoveredlessthan25% ofthelungparenchyma,withalargeright-sidedpneumothoraxand collapse of the right lung (Figure 2A).Achest drain was inserted withawater-seal.Hereceivedoxygenbyfacemask,amoxycillin+- clavulanate, azithromycin, dexamethasone, and enoxaparin. Clinical conditions improved and the follow-up chest CT confirmed lungexpansion,withright-sidedpleuraleffusionandbilateralconsolidations (Figure 2B). The drain was removed three days after insertion.Oneweekafterhospitalization,hisrespiratorycondition worsened.HewasfebrilewithleucocytosisandincreasedRCP.A newchestCTevidencedsparseground-glassopacities,butalarg- er pleural effusion associated with pleural thickness (Figure 2C). Pleuraldecorticationwasperformed,andpiperacillin+tazobactam andteicoplaninwereprescribed.Vancomycinwasprescribed,due to Staphylococcus haemoliticus vancomycin-sensitive on a cathetertipculture.Fluconazolewasassociated,duetoskincandidiasis on seborrheic dermatitis. Since fever was recurrent and he started diarrhea,anewcourseofpiperacillin+tazobactamwithmetronidazolewasinitiated,withSaccharomycesboulardiiandracecadotril. Clostridiumdificileglutamatedehydrogenasewasnegative.Klebsiellapneumoniaessp.pneumoniaeandPseudomonasaeruginosa amikacin-sensitive were identified on the culture of his calcaneus tissue injury, and he received amikacin. He was discharged home after 86 days of hospitalization.

Case 3 A67-year-old woman presented to the ED complaining fever, confusion, dizziness, drycough, and tachypnea, inthelast sevendays. She had lung emphysema due to previous smoking with oxygen supplementation at least three-quarters of the daytime. She was treating systemic arterial hypertension, dyslipidemia, hypovitaminosis D, and hypothyroidism. She also had a hearing sequela due to previous stroke. She had mild COVID-19 two months before.Shewasafebrile,dyspneicwithmoderateeffort,desaturating atroomair,andhypertensive.Laboratorytestswereunremarkable. SARS-CoV-2wasnotdetected.ChestCTevidencedacentrolobularemphysemaandalargeleftpneumothoraxwithamildright-deviated mediastinum (Figure 3). Low-flow oxygen was provided, and she received azithromycin and piperacillin+tazobactam, corticosteroids,bronchodilators,codeine,andthromboprophylaxis.A chest drain was inserted, connected to a water-seal. Bullectomy and pleurodesis were performed 5 days after tube insertion, becauseofahigh-flowairdrainage.Chesttubewasremoved5days later. She was discharged home after 14 days of hospitalization.

Case 4 A previously healthy 22-year-old man with COVID-19 was admittedafteroneweekofsorethroatanddrycough.Atadmission, he was dyspneic with moderate effort, desaturating, tachycardic, andnormotensive.Hedeniedsmoking.HehadelevatedRCP.The other blood tests were unremarkable. Chest CT showed groundglass opacities covering more than 50% of the lung parenchyma and few consolidation foci (Figure 4A). A mild-to-moderate bilateralpneumothoraxassociatedwithpneumomediastinumand pneumopericardium was also noted. Oxygen was offered by face mask. He received dexamethasone, thromboprophylaxis, and amoxycillin+clavulanate and azithromycin. His respiratory effort worsened, and he was intubated and mechanically ventilated in proneposition.Twochesttubeswereinsertedinbothhisrightand left hemithoraces, all connected to water-seals. Chest tubes were withdrawn after four days. He self-extubated three days later. He was discharged home, with a normal chest CT and breathing at room air (Figure 4B).

3. Discussion Since the beginning of the pandemic, many cases of COVID-19 associated SP were reported. SARS-CoV 2 causes a diffuse alveolar damage with perivascular immune cell infiltration, severe end othelialinjury, and wide spread thrombosis, whichmay lead to air leak and dilatation of some alveoli and hemorrhagic/ edematous collapse of others. 2 The final rupture of the alveolar wallisaconse quence of ashearstress (e.g.,coughing), developing a communication with the pleural space. Ultimately, COVID-19 may also be considered a cause of SP. However, it should be highlighted it is an unusual complication of COVID-19 (relative frequency of 0.57‰), although more common in affected than in non-affected individuals.1, 2 Arecentcase -controlstudydescribed 40 COVID -19-associated SP (i.e., without previous positive -pressureventilation, chestmani pulation or trauma) among71, 904 patients attending in 50 Spanish EDs.3 Patients with COVID-19 who developed SP more frequently were men and their median agesimilartooursearch. 3Theyalsomorefrequentlyhaddyspnea/ tachypnea and chest pain, desaturation, and increased leukocyte count, than those without COVID -19. 3 Another registry held in16 centers in the United Kingdom which reported 20 patientswith COVID -19 -associated SP. 4 Nine patients had the diagnosis of pneumothorax at presentation to the ED, from which fivewere readmissions. 4 All cases we described had the diagnosis of pneumothoraxatadmission,afterimprovingorcomplainingmild symptoms.

4. Conclusion COVID-19 -associated SP is a potentially severe, although rare, complication. Physicians should be aware of this important pneu matosis because it can happenin people with out previousdiag.

References 1. Miro O, Llorens P, Jiménez S. Frequency of five unusual presentations in patients with COVID-19: Results of the UMC19 -S1. Epidemiol Infect. 2020; 148: e189-92.

2. Menter T, Haslbauer JD, Nienhold R. Postmortem examination of COVID -19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction. Histopathology. 2020; 77(2):198 -209.

3. Miro O, Llorens P, Jiménez S. Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019:ACase Control, Emergency Medicine -Based Multicenter Study. Chest. 2021; 159(3): 1241255.

4. Martinelli AW, Ingle T, Newman J. COVID-19 and pneumothorax: A multicentre retrospective case series. Eur Respir J. 2020; 56(5):2002697.

Ricardo Mesquita Camelo. COVID-19-Associated Pneumothorax: Case Reports. Annals of Clinical and Medical Case Reports 2022