SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: A spontaneous pneumothorax is an abnormal atraumatic accumulation of air within the pleural space. It is classified as primary or secondary pneumothorax with multiple associated precipitants or risk factors(1). Here we present a case of spontaneous pneumothorax following COVID-19 pneumonia.
CASE PRESENTATION: A 58-year-old Hispanic male, known to have hypertension, presented to the emergency room for dyspnea for one day. This was associated with a non-productive cough, fever and pleuritic left-sided chest pain. He denied any smoking history, recent travel, trauma or ill-contacts. There was no known history of lung disease, autoimmune illnesses or family history of pneumothorax. He reported only taking hydrochlorothiazide and amlodipine. Initial vitals were normal, except a respiratory rate of 25 breaths per minute. Pertinent examination findings were, he was of normal height with tachypnea and diminished air entry over the left hemithorax. Laboratory results were positive for COVID-19 by nasopharyngeal swab, with mild leukocytosis, normal procalcitonin and lactic acid. The interleukin-6 level (45.13 pg/mL), ferritin, CPK, LDH and ESR were elevated. Initial chest x-ray and computer tomography (CT) chest showed 30-40% left pneumothorax with patchy bilateral and peripheral coalescing infiltrates, typical of COVID-19 of mild to moderate severity, with a CT severity score (CT-SS) of 12 out of 40. He subsequently had left pigtail placement and was admitted for COVID-19 pneumonia complicated by spontaneous pneumothorax. He was started on antibiotics, hydroxychloroquine and placed on contact and droplet isolation. Ultimately, influenza oropharyngeal swab, urine antigens for mycoplasma and legionella, HIV, collagen vascular screen and blood cultures were otherwise unremarkable. After 8 days, he clinically improved with complete resolution of the pneumothorax post pigtail removal.
DISCUSSION: In the United States, the incidence of adult males with primary or secondary spontaneous pneumothorax is 7.4-18/100,000 or 6.3/100,000, respectively(2). There are several known risk factors for pneumothorax such as smoking, tall stature, family history and certain genetic disorders. Our index case, with the exception of male gender, exhibited none of these precipitants and had no known history of lung disease or any other risk factors for spontaneous pneumothorax. Sun et al,(3) proposed that diffuse alveolar injury due to COVID-19 may increase the risk of alveolar rupture resulting in pneumothoraces. Another theory included a prolonged cough that is associated with COVID-19 pneumonia.
CONCLUSIONS: Healthcare providers should consider patients with COVID-19 pneumonia to be, directly or indirectly, predisposed to spontaneous pneumothoraces. To the best of our knowledge this is the first reported local presentation of spontaneous pneumothorax in a patient with COVID-19 pneumonia.
Reference #1: McKnight CL, Burns B. Pneumothorax. [Updated 2020 Mar 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441885/
Reference #2: Costumbrado J, Ghassemzadeh S. Pneumothorax, Spontaneous. [Updated 2019 Dec 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459302
Reference #3: Sun R, Liu H, Wang X. Mediastinal Emphysema, Giant Bulla, and Pneumothorax Developed during the Course of COVID-19 Pneumonia. Korean J Radiol. 2020;21(5):541-544. doi:10.3348/kjr.2020.0180
DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response
No relevant relationships by Lorenzo Leys, source=Web Response
No relevant relationships by Alicia Thomas, source=Web Response