An Air of Despair-Spontaneous Pneumomediastinum in Covid-19

Background: Spontaneous pneumomediastinum (SPM) is the presence of free air in the mediastinum which is not preceded by any trauma, instrumentation, or medical procedure. SPM is a recognized complication in various clinical settings, including infections. There have been several reports of pneumomediastinum secondary to invasive ventilation in the current pandemic. However, the occurrence of spontaneous pneumomediastinum has been infrequently described with the background of Covid-19 infection. Case Presentation: A 65-year-old gentleman presented with three days history of fever, cough, and exertional dyspnea to our hospital. He denied any trauma, emesis, chest or neck pain. Past medical history was significant for a remote history of 10-pack-year smoking. On presentation, he was in distress with a respiratory rate of 26, saturating 85% on ambient air and otherwise hemodynamically stable. His chest X-ray showed bilateral infiltrates and subcutaneous emphysema. Complete blood count and electrolyte panel was unremarkable. D-Dimer was 8.47ug/ml with a CRP of 10.8mg/dl. Nasopharyngeal RT-PCR was positive for SARS-COV-2. A CT-Chest showed multifocal ground glass opacities along with pneumomediastinum(fig.1). He was managed conservatively with oxygen supplementation, IV dexamethasone and remdesivir. He was discharged after 7 days of hospitalization with interval resolution of the SPM. Discussion:SPM is an uncommon phenomenon in a viral pneumonia. The development of SPM occurs due to increased intra-thoracic pressures that cause alveolar rupture and leakage of air. It travels along the pulmonary interstitium to reach the mediastinum. The mechanism in Covid-19 is poorly understood but is hypothesized as intense alveolar inflammation that predisposes these patients to such a complication, further precipitated by bouts of cough. Previous reports have described the presence of subpleural bullae or cysts on CT images caused by the infectious process that led to the development of SPM. However, this finding was not present in our patient denoting a different mechanism. Use of non-invasive or mechanical ventilation carries a potential to either cause or exacerbate SPM as well. Conclusion: SPM is an infrequent complication of viral pneumonia. We highlight the importance of this phenomenon in COVID-19 patients with an unknown mechanism. Development of SPM may warrant monitoring for the possibility of pneumomediastinum-related cardiovascular and respiratory complications, especially in those requiring ventilation.