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Extensive Pneumomediastinum in COVID-19 Pneumonia Adetiloye Oluwabusayo Adebola, MD*, Beketova Tatyana, MD, Williams Tabatha, NP and Agarwal Sanket, MD

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Extensive Pneumomediastinum in COVID-19 Pneumonia Adetiloye Oluwabusayo Adebola, MD*, Beketova Tatyana, MD, Williams Tabatha, NP and Agarwal Sanket, MD ISSN: 2378-3516 Adebola et al. Int J Respir Pulm Med 2021, 8:151 DOI: 10.23937/2378-3516/1410151 Volume 8 | Issue 1 International Journal of Open Access Respiratory and Pulmonary Medicine CASe RePORT Extensive Pneumomediastinum in COVID-19 Pneumonia Adetiloye Oluwabusayo Adebola, MD*, Beketova Tatyana, MD, Williams Tabatha, NP and Agarwal Sanket, MD Department of Internal Medicine, Metropolitan Hospital Center, New York City Health + Hospitals Corporation, USA *Corresponding author: Adetiloye Oluwabusayo Adebola, MD, Department of Internal Medicine, Metro- politan Hospital Center, New York City Health + Hospitals Corporation, 1901 1st Avenue, Suite 705, New Check for York, NY 10029, USA, Tel: +16465463690 updates described in patients with interstitial lung disease [8,9]. Abstract Only a few cases have been described in patients with Pneumomediastinum, defined as the presence of air in the COVID-19 infection [10,11]. This report highlights SPM mediastinum often occurs due to trauma, mechanical venti- lation or surgical procedure. It may also occur spontaneous- as a potential complication of COVID-19 pneumonia. ly due to predisposing lung diseases such as asthma and Chronic obstructive pulmonary airway disease (COPD). In Case Report this report, we present a case of a patient with COVID-19 We present a 75-year-old male with hypertension pneumonia without any underlying lung conditions or usual risk factors for pneumomediastinum who developed exten- and hyperlipidemia presented to the ED with a four-day sive pneumomediastinum with pneumopericardium during history of shortness of breath, dry cough and myalgia. the course of hospitalization. Vitals at the time of presentation were remarkable for tachycardia, tachypnea and hypoxia with oxygen satu- Keywords ration 90% on room air. Lung auscultation notable for Spontaneous pneumomediastinum, COVID-19 bilateral rales. Chest radiograph revealed significant airspace disease throughout both lungs consistent Introduction with airspace disease. Initial labs revealed leukocytosis COVID-19 (Coronavirus disease 2019) is a novel dis- (white cell count 25 × 103/mcl), elevated inflammatory ease whose pathophysiology, clinical course, manage- markers (ferritin 988 ng/dl, C-Reactive Protein 39 mg/ ment options and outcomes are still being elucidated. dl, Lactate Dehydrogenase 697 U/L, D-dimer 1244 ng/dl, The disease was first reported in Wuhan China in De- fibrinogen 616 mg/dl, Interleukin-6 323 pg/ml, procalci- cember 2019 and was subsequently named “COVID-19” tonin 2.7 ng/ml), lactic acidosis (Lactic acid 2.6 mmol/L), by the World Health Organization (WHO) on 11 Febru- elevated liver enzymes. COVID-19 PCR test through a ary 2020 [1]. The clinical manifestations of COVID-19 nasal swab returned positive. Patient was admitted for pneumonia vary, ranging from mild flu-like symptoms to severe pneumonia secondary to COVID-19 infection severe ARDS at the other end of the spectrum [2]. Other with superimposed bacterial pneumonia. He was com- commonly reported complications are acute kidney in- menced on supplemental oxygen via nasal cannula on jury, cardiac injury, liver dysfunction, thromboembolic medical floors, hydroxychloroquine, ceftriaxone, azith- disease and pneumothorax [3,4]. According to various romycin, therapeutic doses of subcutaneous enoxapa- literature, Spontaneous pneumomediastinum (SPM) is rin, vitamin C and zinc supplement. an infrequent, benign, and self-limiting condition with Over the next couple of days, his clinical condition mortality generally attributable to underlying disease kept worsening despite medical management with states [5-7]. Although typically seen in patients with worsening of cough and shortness of breath being not- underlying obstructive lung disease, it has also been ed. His oxygen requirement also kept increasing to a Citation: Adebola AO, Tatyana B, Tabatha W, Sanket A (2021) Extensive Pneumomediastinum in COVID-19 Pneumonia. Int J Respir Pulm Med 8:151. doi.org/10.23937/2378-3516/1410151 Accepted: March 29, 2021; Published: March 31, 2021 Copyright: © 2021 Adebola AO, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Adebola et al. Int J Respir Pulm Med 2021, 8:151 • Page 1 of 3 • DOI: 10.23937/2378-3516/1410151 ISSN: 2378-3516 point when he was being maintained on High-flow nasal 80s to 90s, BP was noted to be in the normal range. Ox- cannula at 40 L/min at 60% fraction of inspired oxygen. ygen requirements were at 2L/m through a nasal can- Inflammatory markers during this period trended up nula. EKG showed sinus tachycardia with normal sinus as well. After showing no improvement with hydroxy- rhythm. A CT angiogram of chest was performed to rule chloroquine, ceftriaxone, azithromycin and enoxaparin, out a pulmonary embolism. The scan showed no pul- he was started on dexamethasone therapy with no re- monary embolism but surprisingly reported extensive sponse. Given inability to wean oxygen and worsening pneumomediastinum and pneumopericardium extend- clinical condition, he received a dose of tocilizumab ing to the soft tissues of the neck and downwards along around day 15 after which his clinical condition start- the descending aorta into the abdomen. Interstitial and ed improving. His oxygen requirement also came down alveolar infiltrates, patchy consolidations predominant- to 5 L/m via nasal cannula. Soon he subjectively started ly in subpleural and peribronchial distribution were also feeling better in terms of the dyspnea but occasionally observed (Figure 1). Following these significant find- continued to complain of chest pain. The chest pain was ings, his oxygen supplementation device was escalated diffuse and initially attributed to the underlying pleuritic to non-rebreather face mask to provide maximal FiO2 pain from COVID-19 pneumonia. in order to facilitate resorption of free air. Aggressive pain management, cough suppressants, stool softeners However on hospital day 28, he reported change in along with strict bed rest activity orders were initiated. the character of the pain which was now much worse. His vitals were monitored closely and he continued hav- He described central chest pain which was sharp, 8/10 ing regular examinations and serial CT scans of chest to in intensity, non-radiating. Auscultation findings of lungs ensure early detection of tension pneumothorax and were unchanged with equal air entry and clear auscul- tension pneumomediastinum. With the above treat- tation bilaterally. His heart rate was noted to be high ment, his chest pain kept improving and serial imaging as well around 110s to 120s as compared to baseline of of chest revealed improvement of the pneumomedi- Figure 1: Extensive pneumomediastinum and pneumopericardium extending downwards along the descending aorta into the abdomen with interstitial and alveolar infiltrates. There are patchy consolidations predominantly in subpleural and peribron- chial distribution (Day 28 of admission). Figure 2: Pneumomediastinum and pneumopericardium almost completely resolved (Day 38 of admission). Adebola et al. Int J Respir Pulm Med 2021, 8:151 • Page 2 of 3 • DOI: 10.23937/2378-3516/1410151 ISSN: 2378-3516 astinum and pneumopericardium. By hospital day 38, COVID-19 pneumonia necessitates prompt imaging and his pneumomediastinum and pneumopericardium al- close monitoring due to the possibility of spontaneous most completely resolved (Figure 2). He was discharged pneumomediastinum. With the staggering number of home in a stable condition on day 54. COVID-19 cases worldwide, awareness regarding SPM as its serious complication is necessary among clinicians. Discussion COVID-19 virus is capable of producing an exces- Declaration of Interest sive immune reaction in the host leading to extensive We declare no competing interests. tissue damage [2] but the precise mechanism of SPM in COVID-19 is unknown. Based on existing literature, References the likely sequence of events in the development of 1. Wang Y, Wang Y, Chen Y, Qin Q (2020) Unique epidemi- pneumomediastinum could involve rupture of damaged ological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special con- alveolar wall, air dissection along the bronchovascu- trol measures. J Med Virol 92: 568-576. lar sheath, and free air reaching the mediastinum [6]. 2. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli Depending upon tissue planes involved, the air dissec- R (2021) Features, evaluation and treatment coronavirus tion could even extend to cause pneumopericardium, (COVID-19). Stat Pearls Publishing. pneumothorax, pneumoperitoneum or subcutaneous 3. Yang X, Yu Y, Xu J, Shu H, Xia J, et al. (2020) Clinical emphysema [6]. Common triggering factors include course and outcomes of critically ill patients with SARS- events that elevate alveolar pressure such as mechani- CoV-2 pneumonia in Wuhan, China: A single-centered, cal ventilation, Valsalva maneuver or other causes such retrospective, observational study. Lancet Respir Med 8: as central line placements [8]. Vigorous coughing, eme- 475-481. sis or other maneuvers that increase the intrathoracic 4. Sakr Y, Giovini M, Leone M, Pizzilli G, Kortgen A, et al. pressure are also other possible mechanisms [8]. We (2020) Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: A narrative review. hypothesize that persistent
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