key: cord-0833714-aj3o436d
authors: González-Pacheco, Héctor; Gopar-Nieto, Rodrigo; Jiménez-Rodríguez, Gian-Manuel; Manzur-Sandoval, Daniel; Sandoval, Julio; Arias-Mendoza, Alexandra
title: Bilateral spontaneous pneumothorax in SARS-CoV-2 infection: A very rare, life-threatening complication
date: 2020-07-12
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.07.018
sha: f9c626bfbbdc8690a35d5afe8f964024fe725ba4
doc_id: 833714
cord_uid: aj3o436d

In the coronavirus disease 2019 (COVID-19) era, the presence of acute respiratory failure is generally associated with acute respiratory distress syndrome; however, it is essential to consider other differential diagnoses that require different, and urgent, therapeutic approaches. Herein we describe a COVID-19 case complicated with bilateral spontaneous pneumothorax. A previously healthy 45-year-old man was admitted to our emergency department with sudden-onset chest pain and progressive shortness of breath 17 days after diagnosis with uncomplicated COVID-19 infection. He was tachypneic and presented severe hypoxemia (75% percutaneous oxygen saturation). Breath sounds were diminished bilaterally on auscultation. A chest X-ray revealed the presence of a large bilateral pneumothorax. A thoracic computed tomography (CT) scan confirmed the large bilateral pneumothorax, with findings consistent with severe COVID-19 infection. Chest tubes were inserted, with immediate clinical improvement. Follow-up chest CT scan revealed resolution of bilateral pneumothorax, reduction of parenchymal consolidation, and formation of large bilateral pneumatoceles. The patient remained under observation and was then discharged home. Bilateral spontaneous pneumothorax is a very rare, potentially life-threatening complication in patients with COVID-19. This case highlights the importance of recognizing this complication early to prevent potentially fatal consequences.

The outbreak of infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) began in Wuhan, the capital of Hubei Province, China, and then rapidly spread globally [1] . Although most patients with COVID-19 have a good prognosis, in some cases, the disease progresses rapidly, and patients develop acute respiratory distress syndrome (ARDS), the most severe form of acute lung injury seen in patients with COVID-19, leading to a very high mortality rate among those requiring mechanical ventilation [2] . Some evidence suggests that ARDS has been closely related to very high levels of proinflammatory cytokines, or a "cytokine storm" [3] .

However, large bilateral spontaneous pneumothorax (BSP) in those infected with SARS-CoV-2 has not yet been widely reported in the literature [4] . Herein, we report a case of a patient with COVID-19 who developed simultaneous BSP.

On May 17, 2020, a previously healthy 45-year-old male nonsmoker was admitted to the emergency department of our hospital with sudden-onset chest pain and progressive shortness of breath. Seventeen days prior, the patient had been diagnosed with uncomplicated COVID-19, with fever, sore throat, and headache; he had no respiratory distress, and his pulse oximetry was greater than 90%. The test for nasopharyngeal-swab SARS-CoV-2 nucleic acid detection by real-time Continuous suction was used, and complete expansion of the lungs was successful. The chest tubes were removed on the ninth day. Follow-up chest CT revealed resolution of the previous bilateral pneumothorax, reduction of parenchymal consolidation, and formation of large bilateral pneumatoceles ( Figure   2 ). The patient remained under observation over the next three days, while he showed significant clinical improvement, after which he was discharged home.

Herein, we report an unusual case of a previously healthy young individual in whom the initial manifestation of acute lung damage from COVID-19 was a simultaneous BSP. The association between COVID-19 and unilateral spontaneous pneumothorax has recently been reported [5, 6] ; however, the presence of large simultaneous BPS in a patient with COVID-19 has not been reported.

In the COVID-19 era, the presence of acute respiratory failure is generally associated with acute respiratory distress syndrome. However, the detection of different acute complications, such as pulmonary embolism [7] and pneumothorax [5, 6] , may require different and urgent therapeutic approaches.

In patients with SARS-CoV-2 infection, acute lung damage is the major contributor to morbidity and mortality. Yet to date, the incidence of spontaneous pneumothorax in these patients is unknown. Chest computed tomography studies have shown that pneumothorax is a rare finding, but its actual prognostic significance is J o u r n a l P r e -p r o o f unknown [8] . Nevertheless, the British Thoracic Society considers both spontaneous tension pneumothorax and SBP to be potentially life-threatening events that require urgent chest drain insertion [9] . Flower et al. [5] and Spiro et al. [10] reported that two patients with SARS-CoV-2 infection developed tension pneumothorax unassociated with mechanical ventilation that caused acute deterioration. In addition, our patient presented acute respiratory failure caused by the development of simultaneous bilateral spontaneous pneumothorax.

Opportune detection by clinical examination and confirmed with imaging techniques, in this uncommon complication in COVID-19 patients that show progressive worsening of respiratory function, may avoid use of treatments such as continuous positive airway pressure, which can have catastrophic consequences in these cases.

Many respiratory disorders have been described as causes of spontaneous pneumothorax. The most frequent underlying disorders are chronic obstructive pulmonary disease with emphysema, cystic fibrosis, blebs, tuberculosis, lung cancer, and HIV-associated pneumocystis carinii pneumonia; the presence of BSP is an indicator of advanced lung pathology with a poor prognosis [11] . Although the precise mechanism of spontaneous pneumothorax in COVID-19 is unknown, it may be linked to a variety of factors. The presence of pneumatoceles in patients with COVID-19 [5, 12] is an uncommon pathological finding, which may contribute J o u r n a l P r e -p r o o f 

Potential for global spread of a novel coronavirus from China

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area

The pathogenesis and treatment of the `Cytokine Storm' in COVID-19

Tension pneumothorax in a patient with COVID-19

SARS-CoV-2 Infection Associated With Spontaneous Pneumothorax

Occurrence of Acute Pulmonary Embolism in COVID-19 -A Case Series

Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging Findings

Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline

Secondary tension pneumothorax in a COVID-19 pneumonia patient: a case report

Spontaneous Pneumothorax: Epidemiology, Pathophysiology and Cause

Interpretation of CT signs of 2019 novel coronavirus (COVID-19) pneumonia

Inflammation as a cause of spontaneous pneumothorax and emphysema-like changes: results of bronchoalveolar lavage