Medical Case Reports

Keywords

COVID-19; Spontaneous; Pneumomediastinum; Pneumopericardium

Introduction

Some case reports present occurrences of extra-pulmonary air extravasation as a complication of the coronavirus disease 2019 (COVID-19), most commonly in patients on mechanical ventilation. Few reports depict these findings in non-ventilated patients, and even fewer identify concurrent pneumomediastinum and pneumopericardium. We present the case of a 21-year-old male with no significant comorbidities and an uncomplicated course of COVID-19 developing spontaneous pneumomediastinum and pneumopericardium.

Case Report

A 21-year-old male presented to the emergency department with 2 weeks of progressively worsening cough, shortness of breath, fever, pharyngitis, nausea and vomiting. He had tested positive for COVID-19 1 week prior. On admission, his temperature was 39.8°C, heart rate 125 beats per minute, blood pressure 136/82 mmHg, respiration rate 36 breaths per minute, oxygen saturation of 88% on room air. Initial labs in Table 1 showed markedly elevated inflammatory markers. Computed tomography of the chest showed bilateral, patchy ground glass opacities and concurrent pneumomediastinum and pneumopericardium (Figure 1). He required 4 liters of oxygen via face mask to attain oxygen saturations of 96% but had stable respiratory and cardiac symptoms. Consultation with thoracic surgery recommended no intervention unless respiratory symptoms worsened.

Figure 1: Upright chest X-ray (A) and CT of the chest (B-D) indicating pneumopericardium (red arrows) and pneumomediastinum (blue arrows).

The patient was treated with Remdesivir 200 mg three times between hospital day 2 to discharge on day 4 with improving inflammatory markers and an oxygen saturation of 94% on room air. A repeat chest X-ray was found to be stable and he was discharged with home oxygen and guaifenesin 600 mg as needed for cough.

Discussion

While pneumomediastinum and pneumopericardium in the setting of COVID-19 are prevalent among mechanically ventilated patients, few cases have been noted in non-ventilated patients without pulmonary barotrauma. Furthermore, this simultaneous presentation is unusual [1]. A recent literature review by Quincho- Lopez and colleagues identified 5 cases of pneumomediastinum in non-ventilated COVID-19 patients, with an ufavorable disease progression in 50% of cases. Spontaneous pneumomediastinum typically resolves on its own; however, it can cause cardiac tamponade, and has been associated with poor outcomes with COVID-19 [2,3]. This highlights the importance of elucidating its prevalence and its relationship with disease course.

Although the mechanism is not fully understood, Lei (2020) proposes that peribronchial abscess formation from COVID-19 infection causes pulmonary emphysema followed by air tracking along bronchovasculature resulting in spontaneous pneumomediastinum [4]. We hypothesize a similar mechanism for the progression of air into the pericardium. With the 2002 Severe Acute Respiratory Syndrome coronavirus, pneumomediastinum most often occurred when ground glass opacities began to resolve and among males, which was consistent with our patient [5].

Conclusion

In summary, although the etiology and clinical impact of spontaneous pneumomediastinum and pneumopericardium in COVID-19 has yet to be elucidated, clinicians should be aware of its potential for worsening disease. Notably, recent case studies suggest that spontaneous air extravasation in patients on mechanical ventilation following COVID-19 infection have poorer prognoses and worse outcomes. On their own, both pneumomediastinum and pneumopericardium have the potential to cause adverse outcomes, and their impact in COVID-19 is not yet known. This unique case adds to the growing body of evidence regarding COVID-19 and its extrapulmonary manifestations.

Funding

None.

Conflicts of Interest/Competing Interests

The authors declare that they have no competing interests.

Ethics Approval

Not applicable. No participants were enrolled in this case report.

Consent to Participate

Not applicable. There is no identifiable information in this case report.

Consent for Publication

Not applicable. There is no identifiable information in this case report.

Authors' Contributions

TE and NS wrote the majority of the manuscript. NS created manuscript figures and TE performed background research. MK cared for this patient and contributed with ongoing editing and manuscript improvements. All authors read and approved the final manuscript.

References

1. Wali A, Rizzo V, Bille A, Routledge T, Chambers AJ (2020) Pneumomediastinum following intubation in COVID-19 patients: A case series. Anaesthesia 75:1076-1081.
2. Quincho-Lopez A, Quincho-Lopez DL, Hurtado-Medina FD (2020) Case Report: Pneumothorax and Pneumomediastinum as Uncommon Complications of COVID-19 Pneumoniaâ??A literature review. Am J Trop Med Hyg 103:1170-1176.
3. Zhou C, Gao C, Xie Y, Xu M (2020) COVID-19 with spontaneous pneumomediastinum. Lancet Infect Dis 20:510.
4. Lei P, Mao J, Wang P (2020) Spontaneous pneumomediastinum in a patient with Coronavirus Disease 2019 pneumonia and the possible underlying mechanism. Korean J Radiol 21:929-930.
5. Hui JYH, Cho DHY, Yang MKW, Wang K, Lo KKL, et al. (2003) Severe acute respiratory syndrome: spectrum of high-resolution CT findings and temporal progression of the disease. Am J Roentgenol 181:1525-1538.