key: cord-1030555-kje2fo6u authors: Schiller, Martin; Wunsch, Andreas; Fisahn, Juergen; Gschwendtner, Andreas; Huebner, Ute; Kick, Wolfgang title: Pneumothorax with bullous lesions as a late complication of COVID-19 pneumonia - a report on two clinical cases date: 2021-05-09 journal: J Emerg Med DOI: 10.1016/j.jemermed.2021.04.030 sha: af7d2fd70c73120cdd93982ab7a52f7fca03fcd8 doc_id: 1030555 cord_uid: kje2fo6u Background: Coronavirus-19 disease (COVID-19) is mainly affecting the respiratory tract, causing viral pneumonia with fever, hypoxemia, and cough. Commonly observed complications include acute respiratory failure, liver or kidney injury, and cardiovascular or neurologic symptoms. In some patients, inflammatory damage results in long term complications like pulmonary fibrosis, chronic pulmonary thrombotic microangiopathy, or neurologic symptoms. The developement of spontaneous pneumothorax is reported as a rare complication mainly in consequence to mechanic ventilation in the criticall ill. Case Report: We report on two cases of COVID-19 pneumonia complicated by a spontaneous pneumothorax and bullous lesions of the lung. Bilateral giant bullae were observed in one of the cases. This complication occurred after an initial resolvement of respiratory symptoms (day 16 and day 29 after COVID-19 treatment was started). Initially, both patients had shown a rather mild course of COVID-19 pneumonia and no mechanical ventilatory support had been necessary. Why Should an Emergency Physician Be Aware of This? In both cases, COVID-19 caused alveolar damage and formation of thoracic bullae with consequent spontaneous pneumothorax as a serious complication. Emergency physicans must be aware of this complication even if the initial COVID-19 symptoms have resolved. Coronavirus-19 disease (COVID-19) is mainly affecting the respiratory tract, causing viral pneumonia with fever, hypoxemia, and cough. Commonly observed complications include acute respiratory failure, liver or kidney injury, and cardiovascular or neurologic symptoms. In some patients, inflammatory damage results in long term complications like pulmonary fibrosis, chronic pulmonary thrombotic microangiopathy, or neurologic symptoms. The developement of spontaneous pneumothorax is reported as a rare complication mainly in consequence to mechanic ventilation in the criticall ill. Case Report: We report on two cases of COVID-19 pneumonia complicated by a spontaneous pneumothorax and bullous lesions of the lung. Bilateral giant bullae were observed in one of the cases. This complication occurred after an initial resolvement of respiratory symptoms (day 16 and day 29 after COVID-19 treatment was started). Initially, both patients had shown a rather mild course of COVID-19 pneumonia and no mechanical ventilatory support had been necessary. Why Should an Emergency Physician Be Aware of This? In both cases, COVID-19 caused alveolar damage and formation of thoracic bullae with consequent spontaneous pneumothorax as a serious complication. Emergency physicans must be aware of this complication even if the initial COVID-19 symptoms have resolved. COVID-19; emphysematous bulla; pneumonia; pneumothorax; remdesivir; SARS-CoV-2 After first reports on a pneumonia of unknown etiology in China, corona virus disease 2019 (COVID-19) has now spread around the whole globe. The disease mainly affects the respiratory tract and causes a viral pneumonia in most of the cases. Common symptoms are fever, cough, dyspnea or respiratory failure. Other manifestations and complications include neurologic symptoms, cardiovascular complications, and gastrointestinal or renal symptoms [1] [2] [3] [4] . While most cases show a rather mild disease course, severe complications have been observed, causing a fatal outcome in affected individuals. These complications include acute respiratory distress syndrome, cytokine release syndrome, secondary infections with septic shock, acute kidney failure, or severe myocardial damage [5] [6] [7] . The development of pneumothorax or pneumomediastinum during COVID-19 disease course is described as a rather uncommon complication, which occurs mainly in critically ill patients or as a consequence of mechanical ventilation [8] [9] [10] [11] . However, recent data suggest that pneumothorax also occurs in patients that did not receive any mechanical ventilation support. The presumed pathophysiological mechanism is diffuse alveolar damage leading to alveolar rupture and air leak [12] . We report on two cases of COVID-19 pneumonia which developed a spontaneous pneumothorax. In both patients, this complication occured rather delayed and after an initial resolution of most respiratory symptoms. However, both patients reported persistent cough. During the initial treatment of COVID-19 pneumonia the patients received supportive therapy including low-flow oxygen supply. Mechanical ventilation or non-invasive ventilation was not performed. One of the patients (case 2) received remdesivir (200mg at day 1 and 100 mg at days 2-5). Both patients had already been discharged after their initial COVID-19 therapy. Pneumothorax was diagnosed at day 16 (case 1) or at day 29 (case 2) after the patients' inital hospitalisation. Symptoms on readmission were thoracic pain, dyspnea, and persistent cough. Pneumothorax with giant bullae in COVID-19 4 Case Report: A 52-year-old male patient was admitted to our hospital with suspected COVID-19 pneumonia. The patient complained about fever (up to 39.0°C), myalgia, and cough. The first symptoms had appeared about 6 days before the admission. There were no known comorbidities despite a history of occasional nicotine consumption. The patient presented in a clinically good condition without shortness of breath (vital signs on admission: heart rate of 90/min, respiratory rate of 18/min, and peripheral oxygen saturation of 91%). Laboratory results showed an elevation of c-reactive protein (CRP: 169.7mg/L; normal range: <5mgl/L) with a normal procalcitonin level (PCT: 0.12 ng/mL; normal range: <0.5 ng/mL). On day + 16 the patient presented again in our emergency department. After an episode of acute coughing the patient had developed thoracic pain and shortness of breath. CT-scan revealed a spontaneous pneumothorax on the right side with a posterior localized bullous lesion ( Figure 1B) . The insertion of a chest tube and subsequent drainage for 24 hours led to a re-expansion of the right lung. The thoracic drain was removed and the patient was dischared after monitoring for two further days. A male patient, 63 years old, was admitted to our clinic after a SARS-CoV-2 infection was diagnosed in the outpatient setting. Comorbidities included a type 2 diabetes, occasional smoking, and arterial hypertension (patient's medication: bisoprolol, felodipine, ramipril, and metformin). In the emergency department, the patient presented with subfebrile temperatures (38.0°C) and cough. There was no shortness of breath and respiratory rate was 20/min. Nevertheless, peripheral oxygen saturation was only 80% and we started oxygen supplementation via a We diagnosed a COVID-19 pneumonia and the patient received supportive treatment (oxygen supplementation, fluid management, paracetamol) plus remdesivir (200mg at day 1 and 100 mg at days 2-5). As CRP and procalcitonin were elevated, we administered an empirical antibiotic treatment with levofloxacine (500mg, at days 1-5). After one week, the patient was discharged in a stable condition (despite a mild, persistent chough). On day + 29 the patient presented again with dry cough and acute onset of chest pain. Computed tomography led to the diagnosis of a left-sided pneumothorax and bilateral giant bullae ( Figure 2B ). We inserted a chest tube for initial treatment of the pneumothorax. After re-expansion of the left lung the patient underwent thoracoscopic bullectomy and pleurodesis with talc poudrage. The lung expanded well and pleural cavity was drained for four subsequent days. After this, the patient was discharged in a good clinical condition. On day + 60 a chest CT confirmed complete expansion of the left lung. The right sided bulla was still present ( Figure 2C ). Histopathology (left sided bulla and pulmonary tissue) showed an emphysematous expanded lung parenchyma with mild interstitial inflammation. A subpleural lymphoid hyperplasia was seen, indicative of a subacute viral infection. Further, we found a mild concomitant vasculitis ( Figure 2D) . A second thoracoscopic intervention and right-sided bullectomy was performed and postoperative x-ray of the chest ( Figure 3B ) showed good postoperative result with a completely expanded right lung. We report on two patients that developed a spontaneous pneumothorax and thoracic bullae after recovery from COVID-19 pneumonia. The initial disease course of these patients was rather uncomplicated and neither of the patients required invasive ventilation. On readmission, however, we observed acute clinical deterioration, thoracic pain and worsening dyspnea. Pneumothorax is described as a rare complication of COVID-19, which is mainly observed during a severe disease course or in the context of positive pressure ventilation. The mechanisms leading to pneumothorax formation are only partially understood. Direct alveolar damage with subsequent air leak has been discussed and mechanical ventilation causing barotrauma might promote this process [13] . Others have postulated that the formation of emphysematous bullae or cavitation might be a consequence of pulmonary infarction, which is probably driven by endothelial inflammation [9] . In one of our cases, alveolar damage and emphysematous expansion of alveoli was histopathologically seen ( Figure 2D ). This observation is in line with other studies (inlcuding COVID-19, SARS-CoV, and MERS-CoV patients), that observed diffuse alveolar damage as the dominant process in most of the cases [14, 15] . Complications of COVID-19, such as pulmonary embolism, myocardial infarction, or acute heart failure may present at the emergency department with similar symptoms [16, 17] . These complications are well known and emergency physicians will be aware of them when taking care of a COVID-19 patient. During the last year, a hypercoagulable state with the risk of thrombembolic complications has been extensively discussed for COVID-19 patients [16] [17] [18] . Therefore, pulmonary embolism might be one of the first supected diagnoses if a COVID-19 patient presents with acute worsening dyspnea. Nevertheless, clinicians must be aware that spontaneous pneumothorax is a serious differential diagnosis in these patients, which requires immediate and adequate treatment. Pneumothorax is a rare complication of COVID-19 pneumonia and persistent coughing may be a warning sign. The recognition of this complication is important for emergency physicians, as other complications such as pulmonary embolism or mycardial infarction can present with similar symptoms. Spontaneous pneumothorax may occur without a correlation to the initial severity of COVID-19 pneumonia. Thus, spontaneous pneumothorax should be in the differential diagnosis of patients with a recent history of COVID-19 and acute worsening dyspnea or acute clinical deterioration. 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C) After thoracoscopic resection of the left sided bulla, a chest CT (day + 60 from the first admission) showed a fully expanded left lung. The right sided bullous lesion is still present. D) Histopathologic findings from lung tissue and resected bulla