• View in gallery
    Figure 1.

    (A) Patchy airspace disease scattered throughout both lungs with a peripheral predominance. (B) A large right pneumothorax with leftward shift of mediastinal structures and re-demonstration of patchy airspace opacities throughout both lungs.

  • View in gallery
    Figure 2.

    An air-filled bulla is seen lateral to the right hilum (arrow). There is a small residual right pneumothorax following right chest tube placement.

  • View in gallery
    Figure 3.

    Computed tomography of the chest demonstrating extensive bilateral infiltrates consistent with COVID-19 pneumonia and a right mid-lung bulla measuring 5.6 cm (anteroposteriorly) by 3.3 cm transversely by 2.7 cm craniocaudally. Transverse view (A) and coronal view (B).

  • 1.

    Sun R, Liu H, Wang X, 2020. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia. Korean J Radiol 21: 541544.

    • Search Google Scholar
    • Export Citation
  • 2.

    Spiro JE, Sisovic S, Ockert B, Bocker W, Siebenburger G, 2020. Secondary tension pneumothorax in a COVID-19 pneumonia patient: a case report. Infection 18: 14.

    • Search Google Scholar
    • Export Citation
  • 3.

    Flower L, Carter JL, Rosales Lopez J, Henry AM, 2020. Tension pneumothorax in a patient with COVID-19. BMJ Case Rep 13: e235861.

  • 4.

    Shi H et al. 2020. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis 20: 425434.

    • Search Google Scholar
    • Export Citation
  • 5.

    Liu K, Zeng Y, Xie P, Ye X, Xu G, Liu J, Wang H, Qian J, 2020. COVID-19 with cystic features on computed tomography: a case report. Medicine 99: e20175.

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Bulla Formation and Tension Pneumothorax in a Patient with COVID-19

Kosuke YasukawaDivision of Hospital Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia

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Arathy VamadevanDivision of Hospital Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia

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Rosemarie RollinsDivision of Hospital Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia

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A 37-year-old man with no significant past medical history presented to the emergency department with a 4-day history of nonproductive cough and shortness of breath. A chest X-ray showed bilateral infiltrates with a peripheral predominance (Figure 1A). Polymerase chain reaction was positive for SARS-CoV-2. The patient developed worsening respiratory distress, was transferred to the intensive care unit, and was placed on a high-flow nasal cannula. He received a course of remdesivir and convalescent plasma therapy. A repeat chest X-ray on day three showed findings similar to those on the initial chest X-ray. His respiratory status improved, and he was discharged on day 12.

Figure 1.
Figure 1.

(A) Patchy airspace disease scattered throughout both lungs with a peripheral predominance. (B) A large right pneumothorax with leftward shift of mediastinal structures and re-demonstration of patchy airspace opacities throughout both lungs.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 3; 10.4269/ajtmh.20-0736

He returned to the emergency department after 14 days complaining of right-sided pleuritic chest pain and shortness of breath of approximately 24-hour duration. A chest X-ray demonstrated a large right pneumothorax with a leftward shift of the mediastinal structures consistent with a tension pneumothorax (Figure 1B). A 16-French thoracostomy tube was emergently placed. A repeat chest X-ray showed the presence of bulla lateral to the right hilum (Figure 2). A subsequent chest computed tomography (CT) demonstrated extensive bilateral infiltrates and a right mid-lung bulla (Figure 3A and B). He remained stable, serial chest X-rays showed diminishing size of the pneumothorax, the chest tube was removed after 5 days, and the patient was discharged.

Figure 2.
Figure 2.

An air-filled bulla is seen lateral to the right hilum (arrow). There is a small residual right pneumothorax following right chest tube placement.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 3; 10.4269/ajtmh.20-0736

Figure 3.
Figure 3.

Computed tomography of the chest demonstrating extensive bilateral infiltrates consistent with COVID-19 pneumonia and a right mid-lung bulla measuring 5.6 cm (anteroposteriorly) by 3.3 cm transversely by 2.7 cm craniocaudally. Transverse view (A) and coronal view (B).

Citation: The American Journal of Tropical Medicine and Hygiene 103, 3; 10.4269/ajtmh.20-0736

Although alveolar rupture due to barotrauma can occur in the setting of invasive mechanical ventilation, there are sporadic reports of spontaneous pneumothorax occurring in patients with COVID-19 who did not require invasive mechanical ventilation.13 Two cases of tension pneumothorax have been reported in non-intubated patients with COVID-19. Similar to Flower et al.’s case, our patient also had a bulla. In our patient, the bulla was not noted on the chest X-ray from the initial admission, indicating formation secondary to his COVID-19 pneumonia. Radiologic studies have shown that patients with COVID-19 pneumonia can develop cystic changes during the course of SARS-CoV-2 infection.4,5 Sun et al.1 reported a formation of a giant bulla and subsequent pneumothorax in a patient with COVID-19. The pathophysiology of cystic changes and bullae formation in COVID-19 is still unknown. Further studies are needed to evaluate the long-term pulmonary consequences of COVID-19 pneumonia and the risk of pneumothorax in patients who recover from the initial acute respiratory failure. The utility of follow-up chest imaging to evaluate bulla formation and other structural changes needs to be investigated.

In conclusion, bulla formation and spontaneous pneumothorax is a possible complication of COVID-19. Spontaneous pneumothorax should be considered in a patient with COVID-19 pneumonia who develops chest pain or acute worsening of dyspnea.

REFERENCES

  • 1.

    Sun R, Liu H, Wang X, 2020. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia. Korean J Radiol 21: 541544.

    • Search Google Scholar
    • Export Citation
  • 2.

    Spiro JE, Sisovic S, Ockert B, Bocker W, Siebenburger G, 2020. Secondary tension pneumothorax in a COVID-19 pneumonia patient: a case report. Infection 18: 14.

    • Search Google Scholar
    • Export Citation
  • 3.

    Flower L, Carter JL, Rosales Lopez J, Henry AM, 2020. Tension pneumothorax in a patient with COVID-19. BMJ Case Rep 13: e235861.

  • 4.

    Shi H et al. 2020. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis 20: 425434.

    • Search Google Scholar
    • Export Citation
  • 5.

    Liu K, Zeng Y, Xie P, Ye X, Xu G, Liu J, Wang H, Qian J, 2020. COVID-19 with cystic features on computed tomography: a case report. Medicine 99: e20175.

Author Notes

Address correspondence to Kosuke Yasukawa, Department of Medicine, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC 20010. E-mail: kosukeyaz@gmail.com

Authors’ addresses: Kosuke Yasukawa, Arathy Vamadevan, and Rosemarie Rollins, Division of Hospital Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, E-mails: kosukeyaz@gmail.com, asv2102@gmail.com, and folksr@gmail.com.

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