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COVID-19 Pneumonitis and Cystic Lung Disease, Pneumothorax And

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COVID-19 Pneumonitis and Cystic Lung Disease, Pneumothorax And Images in Thorax COVID-19 pneumonitis and cystic lung disease, Thorax: first published as 10.1136/thoraxjnl-2021-217390 on 8 July 2021. Downloaded from pneumothorax and pneumomediastinum Serenydd Everden,1 Irfan Zaki,1 Gareth Trevelyan,1 James Briggs2 1Department of Respiratory CASE PRESENTATION Medicine, Royal Berkshire NHS A- 57- year old man with no medical history and Foundation Trust, Reading, UK 2Department of Radiology, Royal <5 pack-year smoking history presented with Berkshire NHS Foundation Trust, dyspnoea. Presentation was 4 days (day 13 from Reading, UK first presentation) post a 9- day admission with COVID-19 pneumonitis (SARS- CoV-2 PCR Correspondence to positive day 0) treated with nasal cannula oxygen Dr Serenydd Everden, and 9 days of dexamethasone. Repeat CXR (day Department of Respiratory Medicine, Royal Berkshire NHS 13) was unchanged and there was no biochemical Foundation Trust, Reading RG1 evidence of bacterial infection. A CT pulmonary 5AN, UK; angiogram (day 13) showed extensive bilateral serenydd. everden@ googlemail. predominantly peripheral subpleural cystic areas com of consolidation, with admixed ground glass changes consistent with COVID-19 pneumo- Received 5 May 2021 Accepted 24 June 2021 nitis (figure 1A). He remained stable and was discharged. He re- presented on day 15 with dyspnoea, oxygen saturations of 83% and left- sided pleu- ritic chest pain. Chest X- ray confirmed left- sided tension pneumothorax, chest drain was inserted, Figure 2 Day 18 CT Thorax: left side pneumothorax, and he improved over 48 hours. Subsequently, pneumomediastinum and subcutaneous emphysema. he deteriorated with pain and swelling around chest and neck. CT Thorax (day 18) showed pneumomediastinum (figure 2) and increased monoxide transfer coefficient (KCO) 0.99 (71% size of the already formed cysts, which were predicted). http://thorax.bmj.com/ Chest clinic now fluid filled (black arrow, figure 1B). In addi- tion, there was a new fluid- filled cyst in an area of previous dense consolidation (white arrow, DISCUSSION figure 1B). These images show changes occurring in severe He was treated conservatively with oxygen COVID-19 pneumonitis across a 4- day period, through venturi masks and discharged 11 days followed by 5- week follow- up imaging. Radiolog- later (day 29). Follow- up CT Thorax, day ical appearances of cyst formation secondary to COVID-19 were described early in the COVID-19 63 from first presentation, showed persisting on September 29, 2021 by guest. Protected copyright. 1 ground glass changes and improvement in size pandemic, but with relatively low prevalence. A of the fluid-filled cystic areas (figure 1C). There rare yet under- recognised complication is that these was complete resolution of pneumomedias- cystic areas may progress to bullae, cavities and 2 tinum and pneumothorax. Follow- up on day 84 pneumothoraces. demonstrated persisting dyspnoea with forced Cavities can occur secondary to bacterial or 3 vital capacity (FVC) 4.86 L (97% predicted), fungal infections and fungal infections may be transfer factor of the lung for carbon monoxide associated with subpleural cysts and pneumothorax. (TLCO) 5.85 (53% predicted) and carbon However, the CRP <10 and procalcitonin of 0.04– 0.18 did not support this, though a beta-D glucan was not sent. In this case, COVID-19 pneumonitis may be associated with subsequent cyst forma- tion (rapid increase in cyst size from 1.2 to 5.0 cm © Author(s) (or their (figure 1A,B, black arrow)), pneumothorax and employer(s)) 2021. No pneumomediastinum. Possible hypotheses include; commercial re- use. See rights and permissions. Published first, cyst formation indicates severe inflammation by BMJ. and therefore may be a covariate risk for pneumo- thorax/pneumomediastinum, second cysts indicate To cite: Everden S, Zaki I, Figure 1 (A) Day 13 CTPA: showing bilateral cystic a greater degree of anatomical changes (not visu- Trevelyan G, et al. Thorax Epub ahead of print: [please areas. (B) Day 18 CT Thorax: progression of known cyst alised on CT) increasing vulnerability to pneu- include Day Month Year]. (black arrow) and formation of new cyst (white arrow). mothorax/pneumomediastinum, and lastly the doi:10.1136/ (C) Day 63 CT Thorax: improvement in size of fluid- filled Macklin effect may explain the development of thoraxjnl-2021-217390 cyst (black arrow). CTPA, CT pulmonary angiogram. pneumomediastinum. Everden S, et al. Thorax 2021;0:1–2. doi:10.1136/thoraxjnl-2021-217390 1 Images in Thorax Primary pneumothorax is unlikely in this case as the patient Funding The authors have not declared a specific grant for this research from any Thorax: first published as 10.1136/thoraxjnl-2021-217390 on 8 July 2021. Downloaded from had no pre- existing lung disease and minimal smoking history. funding agency in the public, commercial or not- for- profit sectors. Secondary pneumothorax due to barotrauma from positive- Competing interests None declared. pressure ventilation may be a risk factor for development of Patient consent for publication Not required. pneumothoraces, however, the patient received no positive- Provenance and peer review Not commissioned; externally peer reviewed. pressure ventilation. This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise CONCLUSION determined by BMJ. You may use, download and print the article for any lawful, Despite the global vaccination programme, COVID-19 in its non- commercial purpose (including text and data mining) provided that all copyright variant forms is unlikely to be eradicated. Patients will continue notices and trade marks are retained. to require respiratory support. This case demonstrates the importance of identifying the formation of cysts in COVID-19 REFERENCES pneumonitis and appreciating that deterioration in patients may 1 Liu K, Zeng Y, Xie P, et al. COVID-19 with cystic features on computed tomography: a case report. Medicine 2020;99:e20175. be resultant from pneumothorax or pneumomediastinum. 2 Martinelli AW, Ingle T, Newman J, et al. COVID-19 and pneumothorax: a multicentre retrospective case series. Eur Respir J 2020;56. doi:10.1183/13993003.02697-2020. Contributors SE: writing main bulk of text, editing, referencing. IZ: conceived [Epub ahead of print: 19 Nov 2020]. idea, editing, image selection. GT: writing first draft of case presentation, editing. JB: 3 Zoumot Z, Bonilla M- F, Wahla AS, et al. Pulmonary cavitation: an under- recognized late advice regarding description of images. Final draft editing. complication of severe COVID-19 lung disease. BMC Pulm Med 2021;21:24. http://thorax.bmj.com/ Chest clinic on September 29, 2021 by guest. Protected copyright. 2 Everden S, et al. Thorax 2021;0:1–2. doi:10.1136/thoraxjnl-2021-217390.
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