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Case Report: Delayed Recurrent Spontaneous Pneumothorax Associated with COVID-19

Ali Gohari

1

, Hossein Mehravaran

2

, Ali Boustani

3

, Mahboubeh Darban

4

, Sara Reshadat

5*

1Department of Internal Medicine, Semnan University of Medical Sciences, Semnan, Iran.

2Department of Internal Medicine, Pulmonary and Critical Care Division, School of Medicine, Mazandaran Universi- ty of Medical Sciences, Sari, Iran.

3Department of Internal Medicine, Semnan University of Medical Sciences, Semnan, Iran.

4Department of Internal Medicine, Semnan University of Medical Sciences, Semnan, Iran.

5*Department of Internal Medicine, Semnan University of Medical Sciences, Semnan, Iran.

Email: [email protected]

ABSTRACT

Rapid spread of the latest Coronavirus infection (COVID-19) issued a big challenge to health-care systems. It took COVID- 19 only few months to be labelled as Pandemic by World Health Organization (WHO). The challenge effects has been vast since there was inadequate information about manifestation and treatment of the new disease. COVID-19 was known as a Respiratory Tract Infecting virus first but soon after it turned into a potentiated worldwide threat, first reports started to un- veil more characteristic conditions of the disease such as olfactory failure and gastrointestinal discomfort. These characteris- tics helped to have a better sight in order to detect patients in initial stages of the disease.

KEYWORDS

Pneumothorax Associated, COVID-19, Interstitial Lung Disease (ILD), Spontaneous Pneumothorax.

Introduction

Since late December 2019, the health-care systems encountered a novel kind of viral disease which caused a pro- found quantity of death and morbidity.(1-3)Additionally, lack of information at the first months made the situation more complicated.(4-6)Some characteristics such as olfactory failure and gastrointestinal discomfort were reported just after the onset of the disease.(7, 8) Nevertheless, as more than a year passed, secondary complications such as COVID-19 associated Pneumothorax merged.(9)Pneumothorax is a condition in which air blows out the lungs into the chest and may cause acute shortness of breath and can be even fatal.(10) Usually, it happens either in concurrence with barotrauma during mechanical ventilation or may happen spontaneously.(10) Recent findings show several cas- es in which pneumothorax happens in people with COVID-19 infection even in absence of mechanical ventilation.(11)Thus, we are not only responsible to take lifesaving actions in acute phases, but realize and prevent further sequels of the disease.Herein, we are going to introduce a patient suffering COVID-19 infection with no coin- cident bilateral pneumothorax.

Case Description

A 64-year-old man admitted to the Emergency Room (ER) with shortness of breath and swelling of right lower ex- tremity. There was no remarkable medical history unless a prior 4-day hospital admission, about four weeks earlier, due to fever, malaise, and dyspnea with a positive RT-PCR for COVID-19. The patient was discharged after relative improvement in order to fulfill his treatment at home. After the discharge, he was totally symptom-free until he expe- rienced an increasing shortness of breath and swelling of the right lower extremity, four days before he was admitted to our emergency ward. On admission, his vital signs indicated a body temperature of 38.1℃, BP: 140/90 mmHg, PR: 100, and a plunged O2 Saturation into 68% that could be corrected to 97% by a 10 lit/min reserve bag. In initial physical examination, there was a decrease in pulmonary sounds in lower right lung. Furthermore, circumference of right leg was 42 cm, 3cm more than left leg’s, and it was tender, warm, and erythematous as well.

According to the findings in physical examination, the patient immediately underwent a pulmonary CT Angiography (CTA) in order to rule out possible pulmonary thromboembolism (PTE). Although no evidence of pulmonary throm- bosis was seen in the Chest CT,Organizing Pneumonitis (OP) and to some extent, Interstitial Lung Disease (ILD)

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was detected in lower lobe of the right lung. [Fig1]

Figure 1.Chest CT with contrast on the first day of admission showing parenchymal involvement

Additionally, Color Doppler Ultra sonography ruled out deep vein thrombosis (DVT) and subsequently, Vancomy- cin, and other spread spectrum antibiotics administrated for possible soft tissue infection due to previous hospitaliza- tion.

Unexpectedly, laboratory examinations resulted in a negative RT_PCR for COVID-19 infection and also an abnor- mal LFT which led the patient underwent liver ultra-sonography (US).[Table1] Regarding to normal US report, LFT alteration could be caused due to the recent inflammation.In addition, a raise in blood BUN and Creatinine was re- ported. As the patient had got no renal dysfunction formerly, it could be interpreted as the effects of nephrotoxic an- tibiotics on kidneys. Therefore, all medications were renal adjusted.

Table 1.Laboratory data of the patient Laboratory Data

Variable Reference Range, Adults Hospital on Evaluation

First Second Third

CBC

Hematocrit (%) 42-50 29.1 32.9 32.6

Hemoglobin (gr/dl) 14-17 9.7 11.1 10.9

White Blood Cells (10^3/μL) 4-10 11.7 14.25 15.9

Differential count (%)

Neutrophils 90.7

Band forms 0

Lymphocytes 10 3 3.4

Monocytes 8.3 5.6 4.5

Eosinophils 0 0.6 0.3

Basophils 0.1 0.1 0.2

Platelets (*10^3/microliters) 150-450 192 141 120

ABO blood type

d-Dimer (ng/ml) Negative

Fibrinogen (mg/dl) Normal

Activated partial thromboplastin time (sec) 30-40 46 65 45

Prothrombin time (sec) 11-15

International normalized ratio 1 1.1 1

Venous blood gas

pH 7.36

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PCO2(mmHg) 44.1

PO2 (mmHg) 26.8

PHCO3 (mmol/l) 24.4

Hemogolobin(g/dl) 12.4

Biochemistry

Sodium (milieq/l) 135-145 140 138 142

Potassium (milieq/l) 3.5-5 4.9 4.7 4.2

Urea nitrogen (mg%) 6-22 20 26 23

Creatinine (mg%) 0.5-1.4 1.6 1.2 0.9

BS 230

Total bilirubin (mg/dl) Protein (g/dl)

Total 6.1-8.3 5.2

Phosphorus (mg/dl) 2.5-5 3.3

Magnesium (mg/dl) 1.8-2.6 2.1

Calcium (mg%) 8-10.6 8.7

Lactate dehydrogenase (iu/liter) Up to 480 504

Alkaline phosphatase (U/liter) 80-306 794 689 540

Aspartate aminotransferase (U/liter) 3-49 152 92 75

Alanine aminotransferase (U/liter) 3-46 145 92 74

Troponin I (ng/ml) Less Than 0.4 0.3 0.2 0.3

Pleural effusion Analysis

Glucose(mg/dl) 217

Protein(g/dl) 3.1

LDH(unit/l) 1917

RBC 100,000

WBC 600

PMN 90

Lymph 10

Urinalysis

pH 5 5

Specific gravity 1.030 1.015

Appearance Turbid Semi-Clear

Color Yellow Yellow

White Blood cells 10-12 4-6

Red Blood Cells 4-6 10-12

Nitrites Negative

Urobilinogen Negative Negative

Albumin Negative Negative

Glucose Negative Negative

Ketones Negative Negative

Blood Negative Negative

Bilirubin Negative Negative

Sediment (per high-power field) (mmol/liter) Negative Negative

Bacteria Negative Negative

White-cell casts Negative Negative

Squamous epithelial cells Negative Negative

Amorphous crystals Negative Negative

Urine Culture No Growth

Sputum Culture Staphsaprophiticus Negative

Galactomannan Less than 0.9 (Negative)

Stool Culture Negative

Stool Exam Normal

CRP Less than 10 Positive+++(107) Positive+++(77) Positive+++

Blood Culture No Growth No Growth

ESR

TIBC(mg/dl) 230-360 90 237

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HBS Antigen Negative

HCV Antibody Negative

Ferritin(ng/ml) 451

On 4th day of admission, dyspnea deteriorated and chest x-ray and chest CT demonstrated a pneumothorax in the right hemi thorax. [Fig2] Subsequently, a chest tube was inserted through his chest wall on the right side and dyspnea was approved dramatically.

Figure 2.Chest CT without contrast on the 4th day of admission showing right hemi thorax Pneumothorax As the patient’s fever did not decrease after 48 hours, blood samples were obtained for Cytomegalovirus (CMV), Interferon-Gamma release assays (IGRA), Galactomannan, and Colistin and antifungal agents replaced the previous regimen. Referring to the obtained results showing CMV infection, which could explain the fever and even pulmo- nary involvements in absence of a positive RT-PCR for COVID-19, Ganciclovir was added to his treatments.

Nevertheless, four days after insertion of the chest tube, dyspnea deteriorated again and the 3rd chest CT illustrated leftside pneumothorax. [Fig3] Although the second Chest tube was inserted immediately, and both chest tubes were working properly, no improvement was achieved in the volume of the Pneumothorax and O2 Saturation lev- el.Thoracic surgery department consultation advised to apply a Negative Pressure set up to reduce the Pneumothorax more effectively. It was also advised to utilizePigtail Catheterization in case of a persistent Pneumothorax. Eventual- ly,the Pneumothorax could not be controlled and he expired due to Bradycardia after 14 days of hospitalization.

Figure3. Chest CT without contrast showing bilateral Pneumothorax on the 8th day

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Conclusion

To summarize our report, delayed pneumothorax in individuals with history of COVID-19 infection may occur even in absence of positive RT-PCR for COVID-19. It can be whether a late sequel of the infection on injured lung tissues or an insidious parallel infection like CMV which can hit a susceptible person with inflamed pulmonary parenchyma receiving Immunosuppressive agents. Therefore, furthered studies are needed to have a better sight on the manifesta- tions of the new disease in order to take appropriate measurements to prevent lung tissue injury during involvement and spread of other infections as well.

References

[1] Cevik, M., Bamford, C., & Ho, A. (2020). COVID-19 pandemic–a focused review for clinicians. Clinical Microbiology and Infection, 26, 842-847.

[2] Khosravi, M. (2019). COVID-19 Pandemic: What are the Risks and Challenges for Schizophrenia?

Psychiatry, 27, 171-178.

[3] Tahaghoghi-Hajghorbani, S., Zafari, P., Masoumi, E., Rajabinejad, M., Jafari-Shakib, R., Hasani, B., &

Rafiei, A. (2020). The role of dysregulated immune responses in COVID-19 pathogenesis. Virus Research.

[4] Gupta, R., & Misra, A. (2020). Contentious issues and evolving concepts in the clinical presentation and management of patients with COVID-19 infectionwith reference to use of therapeutic and other drugs used in Co-morbid diseases (Hypertension, diabetes etc). Diabetes & Metabolic Syndrome: Clinical Research &

Reviews, 14(3), 251-254.

[5] Khosravi, M. (2020). The challenges ahead for patients with feeding and eating disorders during the COVID-19 pandemic. Journal of Eating Disorders, 8(1), 1-3.

[6] Farrokhpour, M., Rezaie, N., Moradi, N., Rad, F.G., Izadi, S., Azimi, M., & Yadollahzadeh, M. (2021).

Infliximab and Intravenous Gammaglobulin in Hospitalized Severe COVID-19 Patients in Intensive Care Unit. Archives of Iranian Medicine, 24(2), 139-143.

[7] Izquierdo-Dominguez, A., Rojas-Lechuga, M.J., Mullol, J., & Alobid, I. (2020). Olfactory dysfunction in the COVID-19 outbreak. Journal of Investigational Allergology and Clinical Immunology, 30(5), 317-326.

[8] Villapol, S. (2020). Gastrointestinal symptoms associated with COVID-19: impact on the gut microbiome. Translational Research, 226, 57-69.

[9] Quincho-Lopez, A., Quincho-Lopez, D.L., & Hurtado-Medina, F.D. (2020). Case Report: Pneumothorax and Pneumomediastinum as Uncommon Complications of COVID-19 Pneumonia—Literature Review. The American journal of tropical medicine and hygiene, 103(3), 1170-1176.

[10] Noppen, M. (2010). Spontaneous pneumothorax: epidemiology, pathophysiology and cause. European Respiratory Review, 19(117), 217-219.

[11] Al-Shokri, S.D., Ahmed, A.O., Saleh, A.O., AbouKamar, M., Ahmed, K., & Mohamed, M.F. (2020). Case Report: COVID-19–Related Pneumothorax—Case Series Highlighting a Significant Complication. The American journal of tropical medicine and hygiene, 103(3), 1166-1169.

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