COVID-19 Pneumonia Associated With Spontaneous Pneumomediastinum and Pneumopericardium
Severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, is spreading around
the world, and the outbreak continues to escalate. Clinical features of
patients with coronavirus disease 2019 (COVID-19) usually include dry cough,
fever, diarrhea, vomiting, and myalgia (1-2). However, atypical presentation
and complications are described (3, 4). The authors report a case of
pneumopericardium, pneumomediastinum, and subcutaneous emphysema associated with
COVID-19.
A 58-year-old nonsmoking man was admitted to IFEMA COVID-19 field hospital with
seven days of fever, occasional cough, and anosmia. Initial physical
examination only showed bibasilar crackles. Chest X-ray showed bibasilar
pneumonia. Analysis revealed mild lymphopenia, and moderate D-Dimer, PCR, and
LDH elevation. The rRT-PCR test was positive for 2019-nCoV. He started
treatment with hydroxychloroquine-ceftriaxone.
On hospital day five, the patient developed dysphonia, dysphagia, pleuritic
pain, and subcutaneous emphysema in the supraclavicular region. His oxygen saturation was maintained at 97%
with O2 at 3L / min through nasal cannula.
A chest X-ray (Figure 1) and CT scan showed cervico-mediastinal
emphysema (Figure 2) with pneumopericardium (Figure 3) and worsening lung
infiltrates without pneumothorax. The authors continued the same treatment and
clinical-radiological follow-up. The patient maintained respiratory stability
without increased oxygen requirements.
Pneumopericardium is a rare condition, occasionally accompanied by
pneumomediastinum, and is usually associated with positive pressure
ventilation, thoracic surgery/pericardial fluid drainage, penetrating trauma,
blunt trauma, infectious pericarditis with gas-producing organisms, and fistula
between the pericardium and an adjacent air-containing organ (5). The clinical
course is usually benign but it can be potentially serious due to pericardial
tamponade (6). The coexistence of pneumopericardium, pneumomediastinum, and
subcutaneous emphysema is very rare and usually occurs in young people with
blunt trauma or asthma (7). None of the processes previously mentioned were
present in this patient, so it was concluded that there was an association with
his COVID-19 pneumonia. Among the atypical manifestations being described by
COVID-19, pneumopericardium has not been reported. Only one patient with
pneumomediastinum has been communicated (2).
Pneumopericardium and pneumomediastinum should be considered in the
differential diagnosis of chest pain or worsening disease in patients with
COVID-19 pneumonia.
References
1. Huang C., Wang Y., Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
2.
Elsevier . 2020. Novel Coronavirus Information
Center. [internet] Acceded 20th April 2020:
https://www.elsevier.com/connect/coronavirus-information-center
3.
G Toscano, F Palmerini, S Ravaglia, L Ruiz, P
Invernizzi, M G Cuzzoni, et al. Guillain-Barré
syndrome associated with SARS-CoV-2. N Engl J Med. 2020 Apr 17. c2009191.
4.
Changyu Zhou, Chen Gao, Yuanliang Xie, Maosheng
Xu. COVID-19 with spontaneous
pneumomediastinum. Lancet Infect Dis. 2020 Apr;20(4):510.
5.
Muñoz Avila JA, Jiménez Murillo LM, Montero
Pérez FJ, Calderón de la Barca
Gázquez JM, Berlango Jiménez A, Durán Serantes M, et al. Pneumopericardium:
review of the literature. Rev Clin Esp. 1994 Oct;194(10):926-928.
6.
Cummings RG, Wesly RL, Adams DH, Lowe JE.
Pneumopericardium resulting in cardiac
tamponade. Ann Thorac Surg. 1984 Jun;37(6):511-518.
