Covid Convalescence Interrupted

INTRODUCTION: Uncertainty and discovery have been two fundamental processes in the response to the Covid-19 pandemic. We continue to recognize new manifestations and complications of this syndrome and its respiratory manifestations. Two recently recognized complications of Covid-19 are pneumothorax and pneumomediastinum with the interesting caveat that these diagnoses can be early manifestations, complications of mechanical ventilation, or can develop late in disease course after other clinical signs have long since begun to improve. Here, we present the case of a young man whose Covid-19 convalescence was disrupted by development of a pneumothorax with early tension physiology. CASE: Our patient was a 34-year-old white, nonsmoking male with a history of asthma and morbid obesity. Five weeks before presentation he was diagnosed with an asymptomatic case of Covid-19 after his symptomatic wife tested positive. Seven days later, he required admission to the ICU for worsening respiratory failure and spent a total of eight days in the ICU receiving oxygen via high-flow nasal cannula but did not require intubation. He was weaned to four liters of oxygen via nasal cannula after a ten day hospitalization and discharged home with instructions to follow up with his outpatient pulmonologist. He was convalescing well with reduced oxygen requirements until 18 days later, when he experienced the sudden onset of worsening dyspnea, prompting him to return to the emergency department. Initial imaging revealed a large left-sided pneumothorax with mediastinal shift and early tension physiology, for which emergency chest tube decompression was performed. His left lung re-expanded immediately after chest tube placement and he was able to rapidly tolerate a clamping trial followed by removal three days later. He was subsequently discharged home. DISCUSSION: The lingering sequelae of Covid-19 infection, including radiographic abnormalities, dyspnea, hypoxemic respiratory failure, and fatigue continue to present challenges for patients and providers. In this case, the sudden worsening of the patient's previously improving clinical course was a key clue to a new etiology of his dyspnea and resulted in appropriate treatment after discovery of the cause. Providers should remain vigilant for pneumothorax in patients with Covid-19, even after their discharge from the hospital.