2 1 serenydd. Accepted 24June2021 Received 5May2021 com 5AN, UK; Foundation Trust, ReadingRG1 Medicine, Royal BerkshireNHS Department ofRespiratory Dr SerenyddEverden, Correspondence to Reading, UK Berkshire NHSFoundation Trust, Foundation Trust, Reading, UK Medicine, Royal BerkshireNHS by BMJ. and permissions. Published commercial re- employer(s)) 2021. No © Author(s) (ortheir Department ofRadiology, Royal Department ofRespiratory thoraxjnl-2021-217390 doi:10.1136/ include DayMonth Year]. Epub aheadofprint: [please Trevelyan G, et al.Thorax To cite: Everden S, Zaki I, everden@ use . Seerights googlemail. cyst (blackarrow). (C) Day63CT Thorax: improvement insizeoffluid- (black arrow)andformationofnew cyst(whitearrow). areas. (B)Day18CT Thorax: progression ofknowncyst Figure 1 ritic chestpain. Chest X- oxygen saturations of83%andleft- discharged. nitis (figure pneumo- changes consistentwithCOVID-19 of consolidation,withadmixed groundglass predominantly peripheralsubpleuralcysticareas angiogram (day13)showedextensivebilateral evidence ofbacterialinfection.ACTpulmonary 13) wasunchangedandtherenobiochemical and 9 positive day0)treatedwithnasalcannulaoxygen pneumonitis(SARS- COVID-19 - first presentation)posta9- dyspnoea. Presentation was 4 <5 pack- A 57- CASE PRESENTATION (TLCO) 5.85 (53% predicted) and carbon transfer factorofthelungforcarbonmonoxide vital capacity(FVC)4.86 demonstrated persisting dyspnoea with forced of thefluid- ground glasschangesandimprovementinsize 63 fromfirstpresentation,showedpersisting later (day29).Follow- through venturimasksanddischarged11days figure of previous dense consolidation (white arrow, tion, therewasanewfluid- now fluidfilled(blackarrow, figure size ofthealreadyformedcysts,whichwere pneumomediastinum (figure chest and neck. CT Thorax (day 18) showed he deterioratedwithpainandswellingaround and heimprovedover48hours.Subsequently, tension pneumothorax,chestdrainwasinserted, tinum and pneumothorax. Follow- was completeresolutionofpneumomedias- Serenydd Everden, pneumothorax and pneumomediastinum COVID-19 pneumonitisandcysticlungdisease, He re- He was treated conservatively with oxygen
year
days ofdexamethasone.R 1B).
presented onday15 (A) Day13CTP year smokinghistorypresentedwith old manwithnomedicalhistoryand Everden S, et al.Thorax 2021;0 :1–2. doi:10.1136/thoraxjnl-2021-217390
filled cysticareas( 1A). Heremainedstableandwas CTPA, CTpulmonaryangiogram. 1 A: showingbilateralcystic IrfanZaki, ray confirmedleft- up CTThorax,day
L (97%predicted), filled cystinanarea day admissionwith
days 2) andincreased figure epeat CXR(day with dyspnoea, 1 up CoV (day 13 from
Gareth Trevelyan, 1B). Inaddi-
sided pleu 1C). There on day 84 -2 PCR filled sided -
pneumomediastinum. Macklin effect mayexplain of the development mothorax/pneumomediastinum, and lastly the alised onCT)increasingvulnerability topneu- a greaterdegreeofanatomical changes (notvisu- thorax/pneumomediastinum, second cystsindicate and thereforemaybeacovariate riskforpneumo- first, cyst formation indicates severe inflammation pneumomediastinum. Possible hypotheses include; tion (rapidincreaseincystsizefrom1.2to5.0 may be associated with subsequent cystforma - pneumonitis was notsent.Inthiscase, COVID-19 0.18 did However, theCRP<10 associated withsubpleural cysts andpneumothorax. ( pneumothoraces. cystic areasmayprogress rare yetunder- fungal infections pandemic, but with relatively low prevalence. were described early in the COVID-19 COVID-19 ical appearances of cystformationsecondaryto followed by5- pneumonitisacrossa4- COVID-19 These images show changes occurring in severe DISCUSSION pneumomediastinum andsubcutaneousemphysema. Figure 2 predicted). monoxide transfer coefficient(KCO) 0.99 (71% figure Cavities can occur secondary to bacterial Cavities canoccursecondaryor 1 James Briggs
1A,B not supportthis, though a beta- Day 18CT , black arrow)), pneumothorax and recognised complicationisthatthese week 2 3 andfungalinfectionsmaybe Thorax: leftsidepneumothorax, follow- 2
and procalcitoninof0.04– Images in Thorax Images to bullae, cavities and up imaging.Radiolog day period, D glucan
1
cm A
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Thorax: first published as 10.1136/thoraxjnl-2021-217390 on 8 July 2021. Downloaded from from Downloaded 2021. July 8 on 10.1136/thoraxjnl-2021-217390 as published first Thorax: http://thorax.bmj.com/
on September 29, 2021 by guest. Protected by copyright. by Protected guest. by 2021 29, September on Chest clinic 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