A 37-year-old man with no significant past medical history presented to the emergency department with a 4-day history of nonproductive cough and shortness of breath. A chest X-ray showed bilateral infiltrates with a peripheral predominance (Figure 1A). Polymerase chain reaction was positive for SARS-CoV-2. The patient developed worsening respiratory distress, was transferred to the intensive care unit, and was placed on a high-flow nasal cannula. He received a course of remdesivir and convalescent plasma therapy. A repeat chest X-ray on day three showed findings similar to those on the initial chest X-ray. His respiratory status improved, and he was discharged on day 12.
(A) Patchy airspace disease scattered throughout both lungs with a peripheral predominance. (B) A large right pneumothorax with leftward shift of mediastinal structures and re-demonstration of patchy airspace opacities throughout both lungs.
Citation: The American Journal of Tropical Medicine and Hygiene 103, 3; 10.4269/ajtmh.20-0736
He returned to the emergency department after 14 days complaining of right-sided pleuritic chest pain and shortness of breath of approximately 24-hour duration. A chest X-ray demonstrated a large right pneumothorax with a leftward shift of the mediastinal structures consistent with a tension pneumothorax (Figure 1B). A 16-French thoracostomy tube was emergently placed. A repeat chest X-ray showed the presence of bulla lateral to the right hilum (Figure 2). A subsequent chest computed tomography (CT) demonstrated extensive bilateral infiltrates and a right mid-lung bulla (Figure 3A and B). He remained stable, serial chest X-rays showed diminishing size of the pneumothorax, the chest tube was removed after 5 days, and the patient was discharged.
An air-filled bulla is seen lateral to the right hilum (arrow). There is a small residual right pneumothorax following right chest tube placement.
Citation: The American Journal of Tropical Medicine and Hygiene 103, 3; 10.4269/ajtmh.20-0736
Computed tomography of the chest demonstrating extensive bilateral infiltrates consistent with COVID-19 pneumonia and a right mid-lung bulla measuring 5.6 cm (anteroposteriorly) by 3.3 cm transversely by 2.7 cm craniocaudally. Transverse view (A) and coronal view (B).
Citation: The American Journal of Tropical Medicine and Hygiene 103, 3; 10.4269/ajtmh.20-0736
Although alveolar rupture due to barotrauma can occur in the setting of invasive mechanical ventilation, there are sporadic reports of spontaneous pneumothorax occurring in patients with COVID-19 who did not require invasive mechanical ventilation.1–3 Two cases of tension pneumothorax have been reported in non-intubated patients with COVID-19. Similar to Flower et al.’s case, our patient also had a bulla. In our patient, the bulla was not noted on the chest X-ray from the initial admission, indicating formation secondary to his COVID-19 pneumonia. Radiologic studies have shown that patients with COVID-19 pneumonia can develop cystic changes during the course of SARS-CoV-2 infection.4,5 Sun et al.1 reported a formation of a giant bulla and subsequent pneumothorax in a patient with COVID-19. The pathophysiology of cystic changes and bullae formation in COVID-19 is still unknown. Further studies are needed to evaluate the long-term pulmonary consequences of COVID-19 pneumonia and the risk of pneumothorax in patients who recover from the initial acute respiratory failure. The utility of follow-up chest imaging to evaluate bulla formation and other structural changes needs to be investigated.
In conclusion, bulla formation and spontaneous pneumothorax is a possible complication of COVID-19. Spontaneous pneumothorax should be considered in a patient with COVID-19 pneumonia who develops chest pain or acute worsening of dyspnea.
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Sun R, Liu H, Wang X, 2020. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia. Korean J Radiol 21: 541–544.
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Flower L, Carter JL, Rosales Lopez J, Henry AM, 2020. Tension pneumothorax in a patient with COVID-19. BMJ Case Rep 13: e235861.
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Shi H et al. 2020. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis 20: 425–434.
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