key: cord-0743889-4mo932w8 authors: Xu, Wenrui; Luo, Xiaojie; Wang, He; Shen, Cheng; Song, Yan; Sun, Tieying; Chen, Min title: Pulmonary emphysema, bullae and pneumothorax in COVID-19 pneumonia date: 2021-01-31 journal: Radiol Case Rep DOI: 10.1016/j.radcr.2021.01.055 sha: 64a3d53c57783ecc27d02b6fcbf6b47cfa17a676 doc_id: 743889 cord_uid: 4mo932w8 In this paper, we described two cases with COVID-19 pneumonia, who developed pulmonary emphysema, bullae and pneumothorax during therapy. In a 48-year-old man with mechanical ventilation, parts of ground glass opacities and consolidations transformed into emphysema and giant bulla, and bilateral pneumothorax were also observed. In a 35-year-old man, localized emphysema and pulmonary bullae were seen in subpleural area in bilateral upper lobes, where no previous lesions were presented. In conclusion, pulmonary emphysema, bullae and pneumothorax could be complications of COVID-19. On one hand, surgical emphysema in ventilated COVID-19 patients was observed as in SARS patients. On the other hand, more serious destruction of lung parenchyma was found in COVID-19 patients. Title Pulmonary emphysema, bullae and pneumothorax in COVID-19 pneumonia In December 2019, a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection broke out in Wuhan, Hubei Province, China. On February 12, 2020, WHO officially named the disease caused by SARS-CoV-2 as Coronavirus Disease 2019 (COVID-19) [1] . As of September 20, COVID-19 resulted in over 30.6 million confirmed cases and 950000 deaths worldwide[2]. Since most COVID-19 infected patients were diagnosed with pneumonia, chest CT played a central role in the diagnosis and management [3] . Several case series and case reports demonstrated the CT features on presentation and its temporal progressions during therapy. In COVID-19 pneumonia, ground glass opacity (GGO) and consolidation emerged from the onset, increasing in number and density, and gradually being absorbed, leaving fibrous changes at the original site [4] [5] [6] [7] . However, only several cases who developed pulmonary bullae or pneumothorax were reported so far [8, 9] . In this paper, we described two cases with COVID-19 pneumonia, who developed pulmonary emphysema, bullae and pneumothorax during therapy. The purpose of this case report is to share our experience in temporal progressions of COVID-19 on CT and alert the clinicians with this clinical situation. A 48-year-old man from Wuhan (the epicenter of the COVID-19 outbreak) presented to local hospital with fever and cough for 5 days. After 15 days' supportive treatment, the clinical symptoms deteriorated and the patient was transferred to our ward in Tongji hospital, Wuhan. On admission to our ward, real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) result for SARS-CoV-2 was positive in oropharyngeal swabs. Screening was positive for influenza A. Therefore, he received supportive treatment for COVID-19 and Tamiflu for influenza A. On day 17 from onset, the patient developed left chest pain at inhalation, and subsequent follow-up chest CT revealed bilateral pneumothorax. High-flow nasal cannula (HFNC) 5 oxygen therapy was initiated, and closed thoracic drainage was performed, until the last follow-up CT scan. No assisted respiration via noninvasive ventilator was given to this patient. From onset to the last follow-up CT scan, the CT images showed a serial transformations of pulmonary lesions. The initial chest CT showed GGOs and patchy consolidations in bilateral lungs, predominantly affecting the subpleural area ( Figure 1A-B) . On day 15, the lesions increased both in extent and density and progressed to multiple consolidations, from peripheral to central area ( Figure 1C-D) . Subsequently, parts of GGOs and consolidations transformed into emphysema and giant bulla, and bilateral pneumothorax were also observed ( Figure 1E-F) . A 35-year-old man from Wuhan was admitted to local hospital due to fever, cough and dyspnea. On admission, a diagnosis of COVID-19 pneumonia, acute respiratory distress syndrome (ARDS), type I respiratory failure and hypoproteinemia was made. Emergency measures were taken, and the patient was treated with antiviral (ganciclovir, oseltamivir) and anti-inflammatory medication (meropenem, linezolid), with supportive care for 35 days in local hospital. On day 36 from onset, the patient was transferred to our ward in Tongji hospital, Wuhan. Initial chest CT on admission showed multiple peripheral GGOs and patchy consolidations in both lungs, which did not spare the subpleural regions ( Figure 2A ). On images obtained on day 12 ( Figure 2B ), day 24 ( Figure 2C ) and day 32 ( Figure 2D ), localized emphysema and pulmonary bullae were seen in subpleural area in bilateral upper lobes, where no previous lesions were presented. More than 100 critically ill patients with COVID-19 had been treated in our ward, among which 2 cases presented with pulmonary emphysema, bullae and pneumothorax during therapy. In contrast with severe acute respiratory syndrome (SARS) pandemic in 2003, COVID-19 has a 6 much lower incidence of pneumothorax, which was reported 12 to 34% in mechanically ventilated SARS patients [5, 10] . However, there existed obvious differences between the two cases. For case 2, assisted respiration via noninvasive ventilator was given to treat ARDS. Localized emphysema and pulmonary bullae appeared in subpleural sparing in bilateral upper lobes, where no previous lesions were present. This was similar to the surgical emphysema in mechanically ventilated SARS patients [9, 10] . Therefore, the use of ventilator may play an important role in the process. In conclusion, we descried two COVID-19 cases with rare CT findings during therapy, suggesting that pulmonary emphysema, bullae and pneumothorax could be complications of COVID-19. On one hand, surgical emphysema in ventilated COVID-19 patients was observed as in SARS patients. On the other hand, more serious destruction of lung parenchyma was found in COVID-19 patients. E-mail address: xuwr0122@163.com 2. Xiaojie Luo, M.D., Department of Radiology, Beijing Hospital Department of Respiratory and Critical Care Medicine, Beijing Hospital Department of Radiology, Beijing Hospital Department of Radiology, Beijing Hospital Department of Respiratory and Critical Care Medicine, Beijing Hospital Department of Radiology, Beijing Hospital World Health Organization. WHO Director-General's remarks at the media briefing on 2019-nCoV on 11 COVID-19): A Perspective from China Coronavirus Disease (COVID-19): Spectrum of CT Findings and Temporal Progression of the Disease Patients with COVID-19 Pneumonia: A Longitudinal Study Coronavirus Disease (COVID-19): Spectrum of CT Findings and Temporal Progression of the Disease Clinical and imaging features of COVID-19. 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