key: cord-0722198-uz0bdajz authors: Ucpinar, Burcin Agridag; Sahin, Cennet; Yanc, Ugur title: Spontaneous Pneumothorax and Subcutaneous Emphysema in COVID-19 Patient: Case Report date: 2020-05-26 journal: J Infect Public Health DOI: 10.1016/j.jiph.2020.05.012 sha: 929588da658c434c5884726d49989306f3ee5128 doc_id: 722198 cord_uid: uz0bdajz Coronavirus disease 2019 (COVİD-19) is an infectious disease caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-CoV-2).As known; COVID-19 has become a global pandemic and serious health problem. Disease mainly affects lungs and common findings are fever cough and shortness of breath. Computerized tomography(CT) has an important role in initial evaluation and follow up of COVID-19. Main (CT) finding of the disease is bilateral extensive ground-glass opacification (GGO) with a peripheral or posterior distribution, mainly involving the lower lobes. In this case report, we present a pneumothorax and subcutaneous emphysema case in a patient with COVID-19. To the best of authors’ knowledge; it is the first illustrated case of pneumothorax accompanying COVID-19 pneumonia. Coronavirus disease 2019 (COVİD-19) is an infectious disease caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-CoV-2). The disease was first seen in J o u r n a l P r e -p r o o f December 2019 in Wuhan; and has been spreading globally; resulting in an global pandemic. [1] At hospital admission; most common symptoms of COVID-19 are fever, cough and shortness of breath. Abdominal pain, myalgia, diarrhea, sore throat, fatigue and loss of smell are other possible symptoms. The diagnosis is made by real time reverse transciption polymerase chain reaction (rRT-PCR) from a nasopharingeal swab. [2] Even not used as routine secreening; imaging with computerized tomography (CT) is strongly recommenden especially in COVID-19 suspected cases on either initial evaluation and follow-up. Known radiologic hallmarks of COVID-19 pneumonia on CT are bilateral extensive ground-glass opacification (GGO) with a peripheral or posterior distribution, mainly involving the lower lobes. Uncommon features can be listed as pleural and pericardial effusion; lymphadenopathy, cavitation, CT halo sign, and pneumothorax. [3] In descriptive study of Chen N et al. which reported the characteristics of 99 patients with COVID-19; they reported that a patient presented with pneumothorax on CT in first admission. [4] In this report; we describe a case of female patient diagnosed as COVID-19 pneumonia with pneumothorax as an initial presentation apparently due to persistant cough. To the best of authors knowledge; it is the second reported case and first radiologically illustated case of pneumothorax accompanying COVID-19 pneumonia. Informed consent of the patient was obtained from herself. An 82 year old female patient was admitted to emergency department with shortness of breath, fever and persistent cough. On physical examination, temperature of the patient was 38.5 degree Celcius, heart rate and respiration rate were 106 and 27 per minute, respectively. Blood pressure was 100/70 mmHg. The initial SpO2 (saturation of peripheral oxygen) was 80 without oxygen and 92 J o u r n a l P r e -p r o o f with nasal oxygen mask. The past medical history was unremarkable. Complete blood count and biochemical analysis were obtained. Due to current ongoing pandemic, COVID-19 was suspected and real-time reverse transcriptase polymerase chain reaction test was performed from the nasopharyngeal swab. A chest computerized tomography (CT) was obtained, due to elderly age of the patient. The CT scan revealed widespread bilateral ground-glass opacities (GGO), predominantly in lower lobes; coherent with COVID-19 lung involvement. Additionally; pneumomediastinum, left sided massive pneumothorax and subcutaneous emphysema in the neck posterior thorasic wall were identified. (Fig. 1a, 1b) Chest tube insertion to the left pleural space was done to drain the excess air in emergency setting. The patient was admitted to the inpatient COVID-19 clinic with a pre-diagnosis of COVID-19 pnemonia. Appropriate treatment with hydroxychloroquine, oseltamivir and ceftriaxone were started. Multiple X-rays of the lungs were obtained to evaluate the lung involvement, pneumothorax and subcutaneous emphysema. General condition of the patient improved day by day. On the following 11th day; pneumothorax and pneumonic infiltrations were totally resolved. Chest tube was remowed and the patient was discharged from hospital. Thus, the lungs are the most affected organs by COVID-19. [6] In patients with COVID-19; chest CT is recommended in suspected patients for both initial diagnosis and follow up. [3] Moreover; CT findings has found to be diagnostic in cases with initial rRT-PCR test was false-negative. [3, 7] Most common lung involvement pattern is bilateral GGO mostly seen in lower lobes with peripheral distribution; as seen in our patient . Pneumothorax is a clinical entity which defined as presence of air between visceral and parietal pleura, which can impair oxygenation and ventilation. Pneumothorax can be classified into three categories as spontaneous (primary or secondary), traumatic and iatrogenic, with spontaneous pneumothroax being the most common type. Secondary spontaneous pneumothorax occurs due toa preexisting lung disease, like pneumonia [9] . Severe strain during persistant cough in COVID-19 pneumonia can be the causative factor for pneumothorax. The present case highlights a rare clinical scenario of spontaneous pneumothorax accompanying COVID-19 pneumonia with CTillustrations. Clinicians should be aware of that pneumothorax can be observed within the radiologic manifestations of COVID-19 pneumonia. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health -The latest 2019 novel coronavirus outbreak in Wuhan About Novel Coronavirus (2019-nCoV)". United States Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging Findings in 919 Patients Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Clinical Characteristics of Coronavirus Disease 2019 in China Functional assessment of cell entry and receptor usage for SARS-CoV-2 and other lineage B betacoronaviruses Chest CT for typical 2019-nCoV pneumonia: relationship to negative RT-PCR testing COVID-19 infection presenting with CT halo sign Spontaneous pneumothorax Nothing to declare.Ethical approval: Not required.