Pneumothorax and pneumomediastinum: a rare complication in the evolution of COVID-19 pneumonia.

74-year-old-man with a dry cough, dyspnea, fever, risk factors for poor evolution (hypertension, diabetes) and data of severity (oxygen saturation of 89, tachypnea) was hospitalized. Reverse transcription-polymerase chain reaction for COVID-19 was positive. Eighteen days after admission he suffered a sudden clinical worsening with pain in the right hemithorax.

Chest x-ray performed at admission showed low-attenuated peripheral opacities in the right lung (figure 1). During hospitalization the patient remained afebrile and eupneic with progressive improvement and normalization of respiratory work. Intubation was not required at any point of its hospitalization. Eighteen days after admission he suffered a sudden clinical worsening with onset of stabbing pain in the right hemithorax and crackles in the middle and lower fields of the right lung. A portable chest x-ray was performed (figure 2) showing worsening of the opacities of the right lung. Blood test depicted a significant increase in D-dimer values, thus pulmonary angio-CT was requested on suspicion of pulmonary thromboembolism (figure 3). Pulmonary thromboembolism was not found, but CT showed right pneumothorax and pneumomediastinum as complications of COVID-19 (figure 4).

Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. Chest imaging tests are not indicated in patients with mild symptoms without risk factors for poor evolution. However, they are indicated in those patients with suspected COVID-19 pneumonia with moderate-severe clinical features and a high pretest probability of disease (combination of age > 65 years and presence of comorbidities as chronic respiratory disease, cardiovascular disease, diabetes, hypertension, immune-compromise) [2]. It should also be considered that chest CT is important in the follow-up for guiding management in patients with COVID-19 pneumonia and worsening of the respiratory status [2].

Among imaging tests, CT pulmonary angiography allows confirming acute pulmonary thromboembolism, as it has been documented its high prevalence in patients with COVID-19 (23%, [95%CI, 15-33%] [3], but also helps recognizing other complications described in these patients, such as pneumothorax or pneumomediastinum [4]. Pneumothorax is an uncommon finding in COVID-19 patients, with a frequency of a 1% in a recent published single-center study [5]. Pneumomediastinum is an extremely rare complication in these patients, according to our knowledge there has been only one published case [6].