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.