Spontaneous Pneumomediastinum/Pneumothorax in Acute COVID-19 Pneumonia: A Case Report

Introduction Spontaneous pneumomediastinum, a rare condition in viral pneumonias, has been increasingly reported during the ongoing COVID-19 pandemic. Emerging literature suggests a higher incidence and mortality in COVID-19 patients with both a pneumothorax and pneumomediastinum. Early recognition and understanding of these complications are necessary to improve outcomes. We present a case of an older man initially diagnosed with mild COVID-19 symptoms who quickly progressed with increasing oxygen levels found to have a small pneumothorax and pneumomediastinum. Description A 77-year-old man with hypertension, obstructive sleep apnea on home continuous positive airway pressure (CPAP) therapy, and diagnosis of mild COVID-19 via reverse transcriptase polymerase chain reaction 1-week prior, presented to the emergency department for worsening shortness of breath. He was found to have a temperature of 101.5°F, heart rate of 103bpm, stable blood pressure, respiratory rate of 25 breaths/minute, and oxygen saturation of 70% on ambient air. He was placed on 15lpm mid-flow. Labs were significant for a white blood cell count of 14k/uL, hemoglobin 11.7g/dL, c-reactive protein 185 mg/L, pro- BNP of 637pg/mL, ferritin 802 ng/mL, lactic acid 2 mmol/L, procalcitonin of 0.84 ng/mL. He had a chest x-ray with bilateral perihilar and lower lobe infiltrates. He was started on dexamethasone, remdesivir, antibiotics, tocilizumab, and enoxaparin. His CPAP was held and continued on oxygen therapy. Discussion Pneumomediastinum, or air in the mediastinum, occurs through various etiologies categorized into secondary and spontaneous. Common secondary causes include blunt injuries by trauma, iatrogenic causes such as intubation, central lines, and chest operations, and finally, medical conditions such as interstitial lung disease, asthma, connective tissue disorders, and respiratory infections may be other causes (1). Several cases have been reported with spontaneous pneumomediastinum in patients with COVID-19, however, the exact etiology is unknown as none were placed on mechanical ventilation (2-5). One mechanism is likely due to the repetitive episodes of cough causing increased airway pressure leading to alveolar rupture in already extensively damaged alveoli and proximal gas leakage (2). Based on one autopsy report, there were findings of desquamation of pneumocytes and hyaline membrane formation indicating early acute respiratory distress syndrome (6). In another case series, barotrauma from higher PEEP (positive end-expiratory pressure) with the use of CPAP is potentially another mechanism (7). Careful consideration for these complications should occur in patients with progressive forms of COVID-19, ensuring cough suppression, use of anti-emetics, diuretics and low PEEP strategy to help mitigate this previously rare phenomenon.