Lung complication in COVID-19 convalescence: A spontaneous pneumothorax and pneumatocele case report

Abstract

An outbreak of novel coronavirus (2019-nCoV) that began in Wuhan, China, has spread rapidly all over the world, becoming pandemic according WHO on March 11, 20201. The typical symptoms of COronaVIrus Disease 19 (COVID-19) can range from mild influenza like syndrome to severe respiratory illness. The elderly population, especially with comorbidities like chronic bronchitis, emphysema, heart failure, or diabetes, is more likely to develop serious illness. Radiographic findings in acute phase of SARS CoV-2 bilateral interstitial pneumonia have been described in several studies. Pilot Computerized Tomography scan studies show lung abnormalities usually reabsorb in 3 weeks without sequelae. Nevertheless, no large studies have done on severity-based chronic lung injury and late pulmonary complications in recovered patients. Pneumothorax and pneumatocele can be two severe lung complications in acute phase and intubated patients, but there is no evidence they can occur during convalescence. We report the first case of a spontaneous pneumothorax due to traumatic (sneeze related) pneumatocele, occurred after recovery from bilateral interstitial pneumonia SARS-Cov-2. *Correspondence to: Lorenzo Rampa, Cardio-Thoracic-Vascular department, San Raffaele Scientific Institute, Milan, Italy, Tel: +393924878243, Email: rampa. lorenzo@gmail.com Received: April 27, 2020; Accepted: May 11, 2020; Published: May 18, 2020 Case report A Hispanic 43-year-old man presented with 10-day history of cough and remittent fever treated with Amoxicillin/Clavulanic acid plus Paracetamol by his general practitioner. Due to persistence of fever and resting dyspnea onset, he was admitted in our hospital, presenting also with headache, anosmia, loss of taste and myalgia. He was a healthy man without any presumed disease, apart from his mild history of smoke until 3 years ago and occasional asbestos exposition related to his job as aerial fitter. He denied family contacts or vaccination for Tuberculosis. The nasopharyngeal swab was positive for SARS CoV-2 and CT scan described extensive bilateral ground glass opacities, especially in middle sections, involving 40% of lung parenchyma, moreover some areas of consolidation with crazy paving pattern. No emphysema or cysts were observed (Figure 1). The patient was treated with oxygen mask (maximum FiO2 40%) achieving good level of oxygen saturation (>95%). Moreover, he started Idroxicloroquine 200 mg bid and Darunavir 800 mg / Cobicistat 150 mg once a day, Azytromicine 500 mg OD, Ceftriaxone 2 g OD and enoxaparin 6000 UI OD. Monitoring Chest X rays showed a mild improvement of bilateral pulmonary lesions, and no pneumothorax. After 17 days, he was weaned from oxygen and clinical symptoms ceased, but he could not guarantee home quarantine. He was transferred to rehabilitation hospital and was declared healed from SARS CoV2 infection after two negative nasal swabs. During his rehabilitation, patient presented with sudden dyspnea, hemoptysis and middle back pain after holding back a sneeze. Chest X-ray showed pneumothorax surrounding left lung and a new cavity with thickened walls in left upper lobe. Some air entrapment was also described between neck muscles (Figure 2). Patient parameters remained stable over time, along with inflammatory markers, but symptoms became more severe, with dyspnea relapse, desaturation to 92% in air and coagula in sputum for several days. After 30 days, CT scan showed a cavitation in left upper lobe (10 × 6,7 × 6 cm) with thicken wall and hydro-air level, without evident bronchial leaks. No pneumothorax was found surrounding left lung and ground glass opacities were persistent in 25% of lung volume. According to radiologist, hydro-pneumatocele or abscess cavity were the two potential diagnosis (Figure 3). In this regard, patient was again transferred to our department, and a CT guided drainage of serum with coagula and air suction was performed. Prophylactic antibiotic therapy with ceftriaxone 2 g once a day was started. Coltural exams did not show any infection, and cytologic assessment showed only serum liquid and blood cells. Patient remained stable after invasive procedure, with resolution of pain and persistent mild dyspnea. Quantiferon test for Tuberculosis resulted negative. CT scan performed after 36 days showed persistence of cavitation and some grade of resolution of ground glass opacities. Patient was discharged home with diagnosis of hydro-pneumatocele in SARS CoV-2 pneumonia. After 60 days from symptoms onset, patients referred persistence of effort dyspnea and asthenia. Follow up CT scan was performed, demonstrating persistence of ground glass opacities in 20% of lung parenchyma, diffuse fibrous stripe, and cavity size halving with clot inside (Figure 4). Rampa L (2020) Lung complication in COVID-19 convalescence: A spontaneous pneumothorax and pneumatocele case report Volume 2: 2-3 J Respir Dis Med, 2020 doi: 10.15761/JRDM.1000115 A B