Pneumomediastinum in a patient with severe Covid-19 pneumonia

A 57-year-old man with no prior medical illness complained of fever and cough for 6 days, followed by breathlessness 3 days later. He had close contact with his daughter-in-law, and was diagnosed with COVID-19 2 days prior. On arrival, he was febrile (body temperature = 38.5°C), not tachypneic, and had oxygen saturation of 99% on room air measured by pulse oximetry. Chest radiography showed ground-glass opacities in the bilateral lower zones. COVID-19 was confirmed by the detection of SARS-CoV-2 in nasopharyngeal and oropharyngeal swab samples using RT-PCR. In the ward, his clinical condition deteriorated with worsening of inflammatory markers and progressive hypoxemia that required oxygen supplementation via face mask on the third day of hospitalization and mechanical ventilation 3 days later. He responded well to intravenous dexamethasone and was extubated after 3 days. Computed tomography of the thorax revealed organizing pneumonia and pneumomediastinum (Figure 1). He still complained of cough but denied chest pain or worsening dyspnea. He received a tapering dose of oral prednisolone and underwent pulmonary rehabilitation in the ward. Pneumomediastinum was managed conservatively owing to general improvement. Oxygen support was weaned off, and he was discharged.

FIGURE 1:
Computed tomography of the thorax showing patchy ground-glass densities and consolidative changes at bilateral dependent portions of the lungs and two foci of air locules at the anterior mediastinum, suggestive of pneumomediastinum (indicated by arrows).

Pneumomediastinum is an uncommon complication of COVID-19 pneumonia. Its spontaneous form has been reported in COVID-19 patients without a history of mechanical ventilation¹. Herein, the occurrence of pneumomediastinum was likely due to a combination of barotrauma and alveolar damage due to SARS-CoV-2 infection. Pneumomediastinum can develop after alveolar membrane damage and rupture, followed by air dissection through the bronchovascular sheath into the mediastinum². It is regarded as a benign condition that requires only conservative management. Patients with pneumomediastinum should be monitored carefully for potential worsening of the disease³.

ACKNOWLEDGMENTS

We express our deepest gratitude to the staff at Hospital Selayang who were involved in the care of the patient.

REFERENCES

• ¹
  Gorospe L, Ayala-Carbonero A, Ureña-Vacas A, Fra Fernández S, Muñoz-Molina GM, Arrieta P, et al. Spontaneous Pneumomediastinum in Patients With COVID-19: A Case Series of Four Patients. Arch Bronconeumol. 2020;56(11):754-6.
• ²
  Murayama S, Gibo S. Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography. World J Radiol. 2014;6(11):850-4.
• ³
  Kangas-Dick A, Gazivoda V, Ibrahim M, Sun A, Shaw JP, Brichkov I, et al. Clinical Characteristics and Outcome of Pneumomediastinum in Patients with COVID-19 Pneumonia. J Laparoendosc Adv Surg Tech A. 2021;31(3):273-8.

• Financial Support: None.

Publication Dates

• Publication in this collection
  23 July 2021
• Date of issue
  2021

History

• Received
  30 June 2021
• Accepted
  07 July 2021