Case Report:
The patient was a 60-year-old male with a history of hypothyroidism and
metastatic rectum adenocarcinoma (diagnosed in 2018) with
retroperitoneal, iliac and mediastinal adenopathies and pulmonary
affectation (a 5mm pulmonary nodule in the inferior right lobe), in
active chemotherapy treatment.
He went to the emergency room with a clinic of cough and expectoration
with two weeks of evolution, and fever with progressive dyspnea (finally
at rest) in the last week. On the pulmonary auscultation presented
roncus and diffuse crackles in the left hemithorax.
Analytically the patient had a PCR 67mg/L, a PCT 0,17ng/mL, a leukopenia
(1,75x109) with lymphopenia (0,26x109 [14,9%]) and a D-dimer of
2133ng/mL. In the chest X-ray was possible to observe an interstitial
patron, with increased diffuse density in lower left hemithorax. Given
the high suspicion of coronavirus infection as a cause of the condition
of the patient (fever + lymphopenia + pneumonia) a PCR for COVID-19 was
requested, being positive.
In the arterial blood gas was observed a respiratory alkalosis and an
acute respiratory distress (pH 7’51, PaCO2 26mmHg,
PaO2 51mmHg, and a calculated
PaO2/FiO2 of 60). Due to the palliative
state of the patient, it was decided to treat the acute respiratory
insuficiency with CPAP, excluding an ICU assistance.
During hospitalization, the patient increased respiratory work and the
oxyhemoglobin saturation was <90% despite a
FiO2 of 50% with Ventimask. It was decided to place a
CPAP of 12 cmH2O, and the patient presented a clinical improve with a
respiratory frequency of 18/min and a 94% saturation with an additional
oxygen of 15 lpm.
After 24 hours of CPAP treatment, the patient presented a sudden
clinical deterioration, with important desaturation,
(SaO2 72%), with an extensive subcutaneous emphysema in
the anterior thorax, up to the neck and both arms.
Given the suspicion of pneumothorax secondary to barotrauma, the
ventilation was interrupted and an urgent chest X-ray was requested,
which didn’t confirm the suspicion. The chest CT scan confirmed a severe
emphysema of thoracic soft parts, important neumomediastinum, right apex
pneumothorax and ground-glass lung opacities in all lung fields,
compatible with COVID-19 infection.” (Figure 1)
A pleural drainage was placed in the small right pneumothorax. The
patient didn’t present any clinical improvement, and maintained
saturations below 80% with oxygen therapy with Ventimask at
FiO2 of 50% and 15 lpm. Due to increased dysneic
sensation, and poor prognosis, it was started a sedation with morphine,
and the exitus occurred in the following hours.