Unusual complication of COVID 19

Contributed by

Dr Balachandra S Bhat. MD

Assistant Professor  Medicine

Yenepoya Medical College Mangalore Karnataka

email : dr.baluymc@gmail.com

Clinical scenario :

A 55 year old male presented to our ER with a history of  cough, sore throat and shortness of breath of 2 days duration. On examination the patient  was conscious , oriented and hemodynamically stable ,oxygen saturation  on room air was 88. He had no comorbid illness .The patient was immediately admitted as suspect COVID and RT PCR for COVID 19 came positive. 

The patient was treated with high flow nasal oxygen , steroids and heparin according to the national protocol in Medical ICU. 

Day 3rd of admission   he suddenly developed tightness around his chest and neck .

On examination he was in severe distress. His heart rate was 130/min .He was tachypneic.On palpation he had crepitus underneath the skin of his right upper limb and chest suggestive of sudden subcutaneous emphysema .

A bedside x-ray chest as shown in Fig1 showed  subcutaneous emphysema and pneumomediastinum.

His respiratory status gradually worsened  and his supplemental oxygen requirements   increased  over the period of time . He was started  on mechanical ventilation and expired few days later.

Subcutaneous emphysema and pneumomediastinum are rare but serious complications of COVID and are noted in non ventilated as well as ventilated patients . 

Similar reports in COVID 19 have been  reported  from Wuhan and the USA.(1,2)

Spontaneous pneumomediastinum is a rare condition, most commonly caused by medical conditions such as asthma, chronic lung disease, infections and mechanical ventilation. While most cases are self-limited and managed conservatively, the condition must be monitored carefully as it can lead to life threatening circulatory and respiratory collapse .

Although the exact mechanism is unknown, increased alveolar pressure and diffuse alveolar injury in severe COVID-19 pneumonia is common which may make the alveoli more prone to rupturing, especially as patients often have a pronounced cough.(1) 

The development of pneumomediastinum in COVID-19 infection is considered a possible indicator of worsening disease, but our patient fortunately survived.

Learning points:

• Spontaneous pneumomediastinum is a rare condition usually seen in patients with underlying pulmonary pathology, infections or mechanical intubation.
• While not commonly seen in viral pneumonias, it has been described in patients with COVID-19 pneumonia, despite no history of mechanical ventilation.
• The presence of pneumomediastinum in patients with COVID-19 infection should alert the clinician to monitor the patients carefully for possible worsening of disease.

References : 

1. Wang J,Su X, Zhang T, et alSpontaneous pneumomediastinum: a probable unusual complication of coronavirus disease 2019 (COVID-19) pneumonia. Korean J Radiol 2020;21:627–8
2. Elhakim TS, Abdul HS, Pelaez Romero C, Rodriguez-Fuentes Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review. BMJ Case Rep. 2020 Dec 12;13(12).