Right hemi diaphragmatic eventration – A rare post SARS-COV-2 infection complication

ABSTRACT

Diaphragm eventration is a rare permanent abnormal elevation of diaphragmatic muscles. They are rare entities with right-sided eventration occurring rarer still. We present a case of a 69-year-old male with right-sided hemidiaphragmatic eventration and post-COVID 19 pulmonary fibrotic changes.

INTRODUCTION

Diaphragm eventration is the permanent elevation of the diaphragmatic muscles, resulting in the abnormal dome of the diaphragm. Depending on the extent of eventration, they can be either partial or complete eventration of one or both hemidiaphragms. The etiology can arise from both congenital as well as acquired, resulting in the presence of the condition in a population of all ages. Unilateral presentations are more common on the left side, with a higher incidence in males. Right-sided eventration is a rare phenomenon.[1-3]

Each hemidiaphragms are supplied by respective phrenic nerves arising from the spinal nerve roots of C3 through C5. Any developmental abnormality or injury can occur to these nerves which provide the motor functions of the hemidiaphragms. They can result in subsequent muscular fiber weakness, and diaphragmatic paralysis, along with decreased lung expansion.[4,5]

COVID-19 infection can lead to decreased muscular fiber structural integrity of the diaphragm, resulting in eventration. The long-term complications remain unknown.[6,7]

We report a case of a 69-year-old male with right-sided eventration presented as a complication of COVID-19.

CASE REPORT

A 69-year-old male presented to us with complaints of cough with expectoration for a year. He is a known case of hypertension and has undergone CABG. He was also infected with COVID-19 two months prior to the presentation.

On general physical examination, the patient was afebrile, well oriented, and normal. Chest auscultation revealed coarse velcro crepitations on the right infrascapular region. Decreased air entry and breath sounds were also noted on the right side.

All routine laboratory investigations were found to be within normal reference value ranges.

Chest X-ray revealed a homogenous opacity in the right lower lobe, showing a complete right hemidiaphragmatic eventration, extending up to the 8^th rib. Calcifications were also seen in the upper margin of the right hemidiaphragms. The right costophrenic angle was also noticeably low.

Bowel loops were seen inferior to the diaphragmatic margin on the right side. Post-COVID 19 fibrotic changes were also seen [Figure 1].

Figure 1.

Chest x ray showing right hemidiaphragmatic eventration and post COVID fibrosis

CT scan of the chest revealed that the right hemidiaphragm was abnormally raised in contrast to the left side. Bowel loops were seen under the right hemidiaphragm. Post-COVID-19 fibrotic changes were also seen in bilateral lung fields.

On the basis of these radiological findings, right hemidiaphragmatic eventration was diagnosed and the patient was started on symptomatic treatment and anti-fibrotic drugs.

A follow-up chest X-ray, 6 months later revealed decreased fibrotic changes but a persistent right hemidiaphragmatic eventration [Figure 2]. The symptoms have subsided and the patient is currently well.

Figure 2.

Follow up xray

DISCUSSION

The diaphragm is a major respiratory muscle that is involved in the ventilatory movements of the lungs. Any etiology of abnormal embryological development or traumatic damage to the innervation of the muscle fiber component can result in diaphragm dysfunction. First reported by Christensen P in 1774, diaphragmatic eventration is a type of diaphragmatic dysfunction where the permanent abnormal elevation of diaphragmatic muscles occurs due to congenital or acquired factors.[1-3]

Congenital eventration occurs due to developmental anomalies and is referred to as true eventration, with a higher incidence on the left side. They are usually asymptomatic and are mostly incidental findings in a chest X-ray. On the other hand, acquired eventration is the result of any nerve injury or dysfunction which is manifested in the diaphragm as muscle fiber weakness, resulting in the loss of muscular structure and rigidity. This leads to the abnormal elevation (more than 2 cm elevation into the chest in comparison with the contralateral side) of the hemidiaphragm on the affected side.[1,2,4]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections are known to cause diaphragmatic weaknesses and paralysis. The increasing incidence of mechanical ventilator-induced respiratory dysfunction is also seen. Phrenic neuropathy due to SARS-CoV-2 infection can result in muscle fiber weakness and cause hemidiaphragmatic eventration, which we believe is the etiology in our aforementioned case report.[6,8,9]

COVID-19 infection leading to diaphragmatic dysfunction causing diaphragmatic eventration is a rare complication and is not widely reported. Unilateral presentations are more common on the left side, and right-sided eventration is an even rare phenomenon.[2,3,7]

The imaging studies such as X-rays and CT scans aid in the detection of the condition. Treatment depends on the symptoms and the severity. In this case, anti-fibrotic drugs and cough-relieving medications have caused a decrease in the chief complaints. No surgical indication was present and hence was not operated on.[10,11]

CONCLUSION

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has left the medical field in question in its wake. The complications, short-term as well as long-term prognosis is still under research, and many rare complications such as this case of right-sided hemidiaphragmatic eventration are reported very scarcely. A rigorous and continuous follow-up is needed to analyze the rare complications of COVID-19 infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.