A young severe COVID-19 case complicated by repeat pneumothorax
Coronavirus disease (COVID-19) has rapidly spread around the world and
has resulted in over four hundred twenty thousand deaths as of June
2020.[1-3]. Many patients with mild COVID-19 have minimal or no
clinical symptoms. However, patients with severe COVID-19 can rapidly
deteriorate and die from acute respiratory distress syndrome and
multiple organ dysfunction syndrome [4,5]. Mechanical ventilation
treatment and extracorporeal membrane oxygenation (ECMO) can be
efficacious for severe and critical cases.
In the current case, a 36-year old male presented to a fever clinic on
Jan 27, 2020, with a fever, cough, and headache. He had traveled to
Wuhan, Hubei Province, China, on Jan 19, 2020. On Feb 3, 2020 (day 8 of
illness), he was diagnosed with COVID-19 by real-time revere
transcription-polymerase chain reaction assay. He was admitted to a
specialist infection ward and received supplemental oxygen, antiviral
treatment, and other symptomatic treatment. The patient’s hypoxemia and
shortness of breath worsened despite receiving high-flow nasal cannula
oxygen therapy (67% concentration) on day 11. Due to this, he was
transferred to the intensive care unit, where he received invasive
mechanism ventilator support. While an intestinal feeding tube was being
placed by gastroscopy on day 15, his heart rate increased, and systemic
pressure dropped. A bedside chest radiograph showed right lung
pneumothorax accompanied by subcutaneous emphysema of the chest wall,
and that the right lung was compressed to less than 10% of the original
volume (Figure 2a). The patient urgently received closed thoracic
drainage. Six hours later, the chest X-ray showed that the lung had
mostly recovered. However, over the next couple of days, because of
severe lung lesions, repeated pneumothorax, and failure of wound healing
due to the positive pressure ventilation, ECMO was started on day 19.
After this, his oxygen saturation values increased to 90-95%, and the
patient’s clinical condition improved. On day 23, a lung X-ray showed
new right lung pneumothorax accompanied by subcutaneous emphysema of the
chest wall and that the lung was compressed to approximately 30%
(Figure 2c). The endotracheal tube was removed on day 24, after which
the pneumothorax gradually improved (Figure 2d). The patient was weaned
off ECMO on day 31. A week later, lung computed tomography (CT) showed
significant improvements in both lung lesions.