Air In The Mediastinum Of A Patient With COVID-19 Pneumonia

Pneumomediastinum on 36th day of hospital admission

Since the outbreak in December 2019, COVID-19 has been evolving, and to date, researches and studies are underway. Every now and then, COVID-19 shows its potential of affecting an organ. Initially thought to be a respiratory virus, it has shown the potential of causing limb ischemia and even myocarditis. There is still more to know about its pathophysiology.

Although COVID-19 may not lead to complications in all of the victims, it surely has life-threatening complications, including tension pneumothorax, cardiac tamponade, significant subcutaneous emphysema, pneumomediastinum, or pneumorrhachis.

A case of complicated SARS-CoV-2 viral pneumonia:

A 34-year-old Hispanic male presented with complaints of non-productive (dry) cough, vomiting, subjective fever, and diarrhea for the past 2 weeks. The patient’s vomitus neither contained blood nor bile. The patient was perfectly fine before presenting with these symptoms; he had no comorbids nor significant past medical history. He was a non-smoker. The patient was admitted for further evaluation.

At the time of admission, the patient was tachycardic with a heart rate of 140 beats per minute, afebrile, and had an oxygen saturation of 90% on room air and 99% on 4 liters per minute nasal cannula.

The patient received a working diagnosis of severe Acute Respiratory Distress Syndrome (ARDS) secondary to SARS-CoV-2 viral pneumonia. The PaO2:FiO2 ratio was 59.

Serological investigation revealed:

  • Normal WBC count
  • Lymphocytopenia of 6%
  • An absolute count of 640/mm3.
  • C-Reactive protein (CRP) of 26.9 mg/dL (elevated)
  • LDH of 353 U/L (elevated)
  • D-dimer levels of 0.66 ug/mL (elevated)
  • Ferritin- 478 ng/mL (elevated)

Imaging:

  1. A plain chest X-ray was performed, which showed bilateral diffuse infiltrates.
  2. A CTPE study ruled out pulmonary embolism but confirmed the presence of patchy bilateral pulmonary consolidation. There were no filling defects nor any evidence of bullous lung disease.

Management:

The patient was started on hydroxychloroquine, azithromycin, and methylprednisolone. He also received tocilizumab and convalescent plasma. Despite treatment, during the hospital stay, his hypoxia worsened, warranting a 100% NRB mask and 6 liters per minute nasal cannula in tandem to maintain his oxygenation.

The patient continued to have hypoxia; even till the 18th day of admission, he had persistent hypoxemia with worsening respiratory distress.

He had to be managed conservatively as he had refused intubation. Gradually his oxygen requirements decreased.

On the 36th day of hospital stay, the patient developed pneumomediastinum, likely secondary to violent coughing. He was managed conservatively.

After 6-weeks of hospital stay, the patient had improved substantially, so a decision was made to discharge him after a chest X-ray. The chest X-ray revealed substantial improvement in the consolidations bilaterally. Pneumomediastinum had resolved too. Therefore, he was discharged home on 2 liters per minute nasal cannula.

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