key: cord-290619-e4h47fo4
authors: Castiglioni, Massimo; Pelosi, Giuseppe; Meroni, Alberto; Tagliabue, Marta; Uslenghi, Elisabetta; Salaris, Davide; Incarbone, Matteo
title: SURGICAL RESECTIONS OF SUPERINFECTED PNEUMATOCELES IN A COVID-19 PATIENT
date: 2020-06-27
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.06.008
sha: 
doc_id: 290619
cord_uid: e4h47fo4

ABSTRACT Emerging studies on radiological findings in COVID-19 patients report a high incidence of bilateral lung involvement, with GGOs imaging being the most common pattern on CT. Cystic lesions, such as pneumatoceles, are rare, although they may occur in 10% of cases. Cyst formation may be explained by a focal pulmonary trauma due to mechanical ventilation and/or infection-related damage to the alveolar walls leading to pneumatoceles. The superinfection of pneumatoceles is a potential life-threating condition for which no standardized therapeutic algorithm has been accepted. We report a case of a COVID-19 patient successfully treated by lung resections for infected pneumatoceles.

In early December 2019, the first cases of pneumonia from SARS-CoV-2 were identified in Wuhan, China [1] . Since then, COVID-19 has become rapidly pandemic causing more than 5.200.000 of cases and 337.000 of deaths worldwide [2] . The most common clinical presentation includes fever, cough, and bilateral GGOs. However, COVID-19 has shown to have a wide spectrum of severity ranging from asymptomatic cases to patients admitted to ICU with ARDS. In some patients, pneumatoceles may occur due to damage to the alveolar walls caused by either the infection or lung ventilation [3, 4] .

Superinfection may represent a potential life-threatening complication of pneumatoceles; in this case, an urgent surgical approach is recommended [5] .

A 55 year-old non-smoker male, arrived at the Emergency Department of the Hospital of Cremona After three weeks, the patient was extubated and NIV was started. The patient was then transferred to the Department of Medicine to continue the medical therapy and oxygen support. Four days later, the patient was re-admitted to ICU and intubated for acute respiratory failure and sepsis. Blood culture results revealed Staphylococcus haemolyticus and specific antibiotics were administered based on the antibiogram report. His clinical condition progressively worsened, high fever persisted as did the septic state, despite antibiotics. Since no evidence of recurrence of COVID-19 pneumonia was detected with a chest X-ray, a CT scan with contrast was requested. Images showed two round cystic 

Emerging reports on radiological findings in patients with COVID-19 have documented high incidence of bilateral lung involvement, with GGOs being the most common pattern on chest CT [1, 3] . Round cystic changes of lung parenchyma are rarely observed in the subclinical period and during the first two weeks after the onset of symptoms, although they occur in up to 10% of patients as the disease progresses [4] . The formation of cystic lesions might be explained by the infection that causes damage to the alveolar walls thus leading to pneumatoceles [4] . Ventilator-induced lung injury might also play a role. In fact, prolonged ventilation with high-lung volumes may cause barotrauma with alveolar and intra-acinar septa rupture; conversely, ventilation with low-lung volumes may cause atelectrauma, especially in patients with ARDS [5] . Of note, interstitial involvement observed in COVID-19 seems similar to those observed in ARDS and compromises both compliance and elastance of the lungs [6] . Recent pathologic examinations of lung specimens from patients with COVID-19 have shown a wide range of lung interstitial inflammation with abundant infiltrating immune cells, alongside thickened alveolar septa and interstitial fibrosis [7, 8] . The histologic specimens documented pus collection inside a cystic dilation of lung parenchyma, which was characterized by acute and chronic inflammation and organizing pneumonia. Remnants of bronchiolar epithelium could be seen along with squamous metaplasia and hemosiderin accumulation (Figure 3 ). These findings favoured 6 newly formed cystic dilation in the peripheral lung parenchyma upon infection and/or barotrauma.

Pneumatoceles complicated by infection require urgent treatment. Although there are no widely accepted therapeutic algorithms for the management of complicated pneumatoceles, some authors advocate early percutaneous drainage as a first-line strategy; on failure of this approach surgical resection should be considered [5] . However, an urgent surgical approach may be preferred in patients with critical clinical conditions since it may be lifesaving. Similarly, we favoured an open-approach to the standard thoracoscopy owing to the failure of prolonged single-lung ventilation. Moreover, the presence of adhesions or incomplete fissures due to the inflammatory process were considered preoperatively. Lung resections were performed conservatively on healthy margins; the aim was to preserve maximum pulmonary function and to prevent postoperative complications, such as air-leaks or peripheral bronchopleural fistula, by excising the infected pneumatoceles completely.

This report describes a COVID-19 patient who was successfully treated by urgent surgery for two infected pneumatoceles causing acute respiratory failure and sepsis that was non-responsive to antibiotics. Although there are no comparable reports, surgical resection of lung lesions as a first-line strategy seems reasonable in a critically ill patient since it may be lifesaving. 

Clinical Characteristics of Coronavirus Disease 2019 in China

World Health Organization

Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study

Ventilator-Induced Lung Injury

Management of complicated pneumatocele

Pulmonary Pathology of Early-Phase 2019 Novel Coronavirus (COVID-19) Pneumonia in Two Patients with Lung Cancer

COVID-19 in the perioperative period of lung resection: a brief report from a single thoracic surgery department in Wuhan