A 51-year-old Caucasian male gardener initially presented to the emergency department (ED) following a 4-day history of shortness of breath, dry cough, and weakness. He had a positive lateral flow test for SARS-CoV-2, and chest x-ray revealed bilateral patchy opacification. He maintained oxygen saturation above 94% on room air so returned home with an oxygen saturation monitor.
Twelve days after onset of symptoms, the patient re-presented to the ED, reporting that his oxygen saturation had dropped to 78%. His chest x-ray showed significant progression of COVID-19 pneumonitis (Figure 1) in comparison with the initial chest x-ray. He was admitted and received oxygen therapy, dexamethasone, doxycycline, and amoxicillin. The antibiotics were later stopped in view of the patient's low procalcitonin (< 0.25) and remaining afebrile. The failure to wean his oxygen and raised D-dimer of 20.0 triggered a computed tomography pulmonary angiogram (CTPA), which ruled out pulmonary embolism (PE). After 3 days as a ward inpatient, he was again able to maintain satisfactory oxygen saturation on room air with a significant reduction in inflammatory markers. He was discharged to complete a 10-day course of dexamethasone.
Twenty-three days after onset of symptoms (8 days after discharge from hospital), the patient experienced a 48-hour period of progressively worsening shortness of breath. He re-presented to the ED, and on examination reduced breath sounds and reduced chest expansion were noted on the right. The patient had a 4 L/min oxygen requirement. He was alert, tachypnoeic (40 breaths/minute), and tachycardic (129 beats/minute), with maintaining blood pressure (116/94 mmHg). Arterial blood gas analysis showed respiratory alkalosis (pH 7.53, PaO2 8.3, PCO2 3.6, HCO3 22.6). The absence of typical clinical signs of tension pneumothorax (hemodynamic instability, tracheal deviation, and raised jugular venous pressure (JVP)) prompted investigation with chest x-ray rather than immediate needle decompression. His chest x-ray showed right-sided tension pneumothorax (Figure 2), which was managed by insertion of 12F pigtail drain using Seldinger technique. The chest drain remained in situ for 4 days before chest x-ray showed adequate resolution of pneumothorax to allow for removal (Figure 3. The patient was discharged following full re-expansion of the lung and resolution of symptoms 5 days post admission. The patient had a follow-up chest x-ray 1 month after discharge, which showed complete resolution of the pneumothorax (Figure 4).
Chest x-ray on initial admission to hospital: Extensive multifocal opacities throughout lungs in keeping with COVID-19 pneumonitis
Chest x-ray of tension pneumothorax: Large right-sided tension pneumothorax causing deviation of the mediastinum to the left. The left lung is compressed
Chest x-ray of tension pneumothorax following chest drain insertion: Partial resolution of tension pneumothorax
His only comorbidity of note was diet-controlled type II diabetes mellitus (HbA1C 64). He had no history of previous trauma, pulmonary disease, or thoracic surgery. There was no reported exposure to asbestos or other hazardous occupational chemicals, and the patient reported no recent activities associated with risk of barotrauma. He was a nonsmoker, independent in all activities of daily living, and had good exercise tolerance. There was no family history of connective tissue diseases or malignancy.
J Med Case Reports. 2022;16(88) © 2022 BioMed Central, Ltd.