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\title{A Pneumothorax in the Setting of COVID-19 Associated Pneumatoceles in a
Pediatric Patient}



\author[1]{Esther Blondeau-Lecomte}%
\author[1]{Nancy Joseph}%
\affil[1]{University of Florida}%


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  \date{May 07, 2024}


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\textbf{A Pneumothorax in the Setting of COVID-19 Associated
Pneumatoceles in a Pediatric Patient}

Esther Blondeau-Lecomte, BA\textsuperscript{1}, Nancy Joseph,
MBBS\textsuperscript{1}

\textsuperscript{1}Department of Pediatrics, University of Florida,
Gainesville, FL, USA

\textbf{Corresponding Author:}

Esther Blondeau-Lecomte, BA

Medical Student

Email Address: eblondeaulecomte@ufl.edu

To the editor,

A 5-year-old male with no significant past medical history presented to
an urgent care with fever, cough, vomiting, and wheezing. He tested
positive for COVID and was sent home with an albuterol inhaler due to
concern for reactive airway disease exacerbation. He initially improved,
but 5 days later, had worsening cough and new acute onset sharp,
stabbing right shoulder pain that did not resolve with acetaminophen.
This development prompted his mother to bring him to the emergency
department (ED). On presentation, the patient appeared in respiratory
distress with tachypnea and an SpO2 88\%. Patient was afebrile. On
physical exam, lung sounds were decreased throughout the right lung.
Cardiac and abdominal exams were normal.

In the ED, a chest x-ray showed a large partially loculated tension
pneumothorax, with consolidation of the right lung and left perihilar
interstitial infiltrate (figure 1). The patient was immediately started
on enoxaparin, ceftriaxone, remdesivir, and dexamethasone. The patient
was subsequently admitted to the intensive care unit, where the
pneumothorax was decompressed with chest tube placement. The patient was
started on azithromycin. After decompression, the patient became
hemodynamically and clinically stable. On a follow-up chest x-ray
examination to evaluate chest tube placement and pneumothorax
resolution, right lung patchy airway opacities, most notably in the
perihilar region, were noted. The patient then underwent computerized
tomography (CT) of the chest which showed a multiseptated 6.4 x 5.1 x
4.8 cm cystic right upper lobe mass, with dependent fluid levels and
subjacent loculated effusion (figure 2). The findings were concerning
for pneumatocele. Pediatric surgery was consulted and determined that
surgical intervention was not necessary. Infectious disease and
pulmonology also recommended continuing ceftriaxone and oral clindamycin
as an outpatient due to the concern for infection. Before discharge, a
repeat CT chest showed a large multilobulated cystic pulmonary mass,
with multiple septations in the apical and posterior segments of the
right upper lobe, similar in size when compared to previous imaging but
with decreased internal fluid. The findings were favored to represent an
infectious pneumatocele over a traumatic pneumatocele. Of note, patient
was retested for COVID on 10 days after his initial positive test and
was found to be COVID negative. In this case, we hypothesize that COVID
associated pneumatoceles led to a pneumothorax resulting in the acute
presentation of this pediatric patient.

Pneumatoceles are air-filled, thin-walled cysts that form in the lung
interstitium. They are often associated with infection, trauma, or with
more extensive lung diseases, and are common in the pediatric
population\textsuperscript{1}. There have been increasing reports of
pneumatoceles in COVID pneumonia adult patients. The pathophysiology
behind COVID-related pneumatoceles is not completely understood, but it
is hypothesized that as the virus targets alveolar epithelial cells and
triggers a cytokine storm, it can lead to alveoli rupture and subsequent
formation of cystic air space lesions\textsuperscript{2}.

Although most cases of COVID related pneumatoceles have been reported in
adults, there are two cases reported in the pediatric population. The
youngest patient described in the literature to have COVID pneumatoceles
is a 20-month-old boy who presented to the emergency department with a 6
day history of cough and was found to be COVID
positive\textsuperscript{3}. The other case was in a 16-year-old with
recurrent B cell acute lymphoblastic leukemia who developed respiratory
failure from COVID and required mechanical
ventilation\textsuperscript{4}.

Our patient therefore serves as an additional documented case of COVID
related pneumatocele in children. However, our patient is unique because
it is the first documented case of pneumothorax associated with
pneumatoceles in a COVID positive pediatric patient. Pneumothoraces are
a known complication of pneumatoceles as edema, vascular congestion, or
microthrombi can result in the rupture of these thin-walled cysts
leading to air accumulation around the lung.\textsuperscript{15}.

Although COVID likely explains the development of the pneumatoceles
progressing to a pneumothorax, we cannot rule out that the pneumatoceles
in our patient were a result of the direct impact from the chest tube
decompression of a spontaneous pneumothorax. However, the chest tube
placement rarely causes pneumatoceles, and the initial radiologic
impression favored pneumatoceles from an infectious source.

As aforementioned, this case is likely the first reported COVID related
pneumothorax in the setting of pneumatoceles in a child. It is
especially interesting given our patient's relatively benign course of
COVID. Before the pneumothorax, he was hemodynamically stable at home
with only mild symptoms. As we learn more about the presentations of
COVID infections, it is important to keep pneumatoceles and their
complications on our differential diagnoses. If a patient shows up to
the ED complaining of acute onset chest or pleuritic pain and dyspnea in
the setting of a COVID infection, it is important to consider pulmonary
embolisms due to the COVID induced hypercoagulable
state\textsuperscript{6}. However, our case also demonstrates that it is
also important to consider COVID induced pneumothoraces.

Furthermore, the case serves as a reminder serves as a reminder of the
importance of COVID precautions and vaccinations in the pediatric
population, as even children with no comorbidities are at risk for long
term sequelae and consequences from a COVID infection. Even if this
patient cleared the COVID infection within 10 days of testing positive,
pneumatoceles remained present and he will require long term antibiotics
and follow up with infectious disease specialists.

To summarize, this patient was a 5-year-old boy who presented to the ED
and was found to have a pneumothorax in the setting of recently testing
positive for COVID. After chest tube placement and lung decompression,
the CT chest demonstrated cystic pulmonary mass with multiple septations
consistent with pneumatoceles. As there have been previous reports of
COVID related pneumatoceles in adults, we hypothesized that this
patient's pneumothorax was directly related to the COVID induced
pneumatoceles.\selectlanguage{english}
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References

1. Jamil A, Kasi A. Pneumatocele. In: StatPearls. Treasure Island (FL):
StatPearls Publishing; 2021.

2. Hamad A-MM, El-Saka HA. Post COVID-19 large pneumatocele: clinical
and pathological perspectives. Interactive Cardiovascular and Thoracic
Surgery. 2021;33(2):322--324. doi:10.1093/icvts/ivab072

3. \selectlanguage{ngerman}Özgür C, Do\selectlanguage{polish}ğ\selectlanguage{english}an C. Multiple pneumatoceles and diffuse ground-glass
opacities in a 20-month-old boy with COVID-19 pneumonia. Respirology
case reports. 2021;9(10):e0842. doi:10.1002/rcr2.842

4. Euroelso 2021 poster abstracts. Perfusion. 2021;36(1\_suppl):4--81.
doi:10.1177/02676591211007763

5. Goldberg C, Carey KE. Bullous lung disease. The Western Journal of
Emergency Medicine. 2013;14(5):450--451.
doi:10.5811/westjem.2013.3.16276

6. Ahuja N, Bhinder J, Nguyen J, Langan T, O'Brien-Irr M, Montross B,
Khan S, Sharma AM, Harris LM. Venous thromboembolism in patients with
COVID-19 infection: risk factors, prevention, and management. Seminars
in vascular surgery. 2021;34(3):101--116.
doi:10.1053/j.semvascsurg.2021.06.002\selectlanguage{english}
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