key: cord-0977471-l3682pay
authors: Peeters, Karen; Mesotten, Dieter; Willaert, Xavier; Deraedt, Karen; Nauwelaers, Sigi; Lauwers, Geert
title: SALVAGE LOBECTOMY TO TREAT NECROTIZING SARS-CoV-2 PNEUMONIA COMPLICATED BY A BRONCHOPLEURAL FISTULA
date: 2020-12-03
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.10.038
sha: e08fa5bb6374c9749e281c11a8bc3772d1ca6269
doc_id: 977471
cord_uid: l3682pay

We report a case of necrotizing SARS-CoV-2 pneumonia complicated by bronchopleural fistula and treated by decortication and salvage lobectomy. Due to the unknown characteristics of the underlying SARS-CoV-2 infection, treatment of the abscess and bronchopleural fistula was delayed. This may have let the patient to further deteriorate with ensuing multiple organ dysfunction. Complications of SARS-CoV-2 pneumonia, such as a bacterial abscess and a bronchopleural fistula, appear to be treated as if the patient was not infected with SARS-CoV-2.

3-5% of the SARS-CoV-2 infected patients evolve into a severe acute respiratory distress syndrome (ARDS) requiring endotracheal intubation and mechanical ventilation. Respiratory viral infections are known to predispose to bacterial co-infections. These may result in empyema and other destructive lung infections. Administration of anti-inflammatory drugs such as steroids may facilitate this.

A 36-year old Caucasian female presented to the emergency department with cough, fever and thoracic pain. She was 8 weeks pregnant and the diagnosis of SARS-CoV-2 had been confirmed five days earlier by RT-PCR assay of a nasopharyngeal swab. Blood test revealed mild C-reactive protein increase (47 mg/L), hyperleukocytosis (20 200/mm3) with lymphopenia and acute kidney injury (creatinine clearance of 52 mL/min/1.73m 2 ). Blood gas analysis showed compensated lactic acidosis (pH 7.47, lactate 3.7 mmol/L), a pO 2 of 69.80 mmHg and a pCO 2 of 28.40 mmHg. There was a patchy infiltration of the right lung on chest X-ray, suggestive for infection.

The patient was admitted to the intensive care unit. Empiric treatment with ceftriaxone and hydroxychloroquine was initiated. Non-invasive respiratory support was provided by High Flow Nasal Canula. Restrictive fluid management and blood pressure control by noradrenaline was started. CT-scan revealed an extensive pneumonia with bilateral, multiple areas of consolidation, necrosis and cavity formation in the right upper lobe (FIG 1) . instability and ongoing blood loss through the chest tubes warranted a revision that same night. There was only diffuse oozing because of coagulation derangements (mainly low fibrinogen levels) and the thoracic cavity was packed. After this intervention, the patient's hemodynamics significantly improved. Three days later the patient underwent a rethoracotomy and removal of the packs. When retrospective reviewing the CT-images, we were able to identify the bronchopleural fistula, arising from the posterior wall of the abscess cavity (FIG 2) .

Histopathologic examination revealed diffuse alveolar damage in the acute and organizing phase and a large necrotic abscess. Intraoperative cultures remained negative.

On day 31, weaning from ECMO was initiated. Two days later, a tracheostomy was placed with the purpose to support weaning from mechanical ventilation. This was complicated by bleeding, initially treated with pharyngeal packing but a complete obstruction of the trachea by blood clots ultimately required surgical revision. On day 40, after 20 days on ECMO, she was successfully decannulated and separated from ECMO and weaning from mechanical ventilation was initiated. On day 47 and day 51 the chest drains were removed. Removal of the tracheostomy was only possible after intensive physiotherapy for severe ICU acquired muscle weakness (after 48 days of mechanical ventilation). The patient was discharged to a non-COVID-19-ward 59 days after being admitted to the hospital.

Our patient developed a hydropneumothorax due to a bronchopleural fistula which occurred as a complication of an extensive necrotizing SARS-CoV-2 pneumonia. Necrotizing pneumonia with secondary bronchopleural fistula and hydropneumothorax is such a rare complication that an incidence has not been reported. In critically ill patients with SARS-CoV-2, significant abnormalities in coagulation parameters have been reported [2] . Emphasis has been placed on prevention of thromboembolic complications by prophylactic treatment with low molecular weight heparin [3] . Although the incidence of hemorrhagic complications in patients with SARS-CoV-2 appears to be low, we noticed several bleeding complications. Therefore, we support the suggestion of Goursaud et al. that ECMO and escalated doses of anticoagulation for tromboembolic event prophylaxis in severe SARS-CoV-2 patients must be considered with caution [1] .

To our knowledge this is the first report of SARS-CoV-2 pneumonia treated with ECMO and ultimately decortication and salvage lobectomy. Aiolfi et al. reported the management of persistent iatrogenic pneumothorax with thoracoscopy and bleb resection in two intubated SARS-CoV-2 patients [4] . However, after a thorough and comprehensive literature search, we found no other reports of surgical treatment of complicated SARS-CoV-2 pneumonia.

Although we do not recommend this treatment as first line option, decortication and salvage lobectomy were successful as salvage therapy.

In conclusion, complications of a severe viral pneumonia, such as bacterial surinfection, abscess formation and bronchopleural fistula, need to be promptly treated. It appears that SARS-CoV-2 infection should not play a determining factor in delaying necessary treatments as it only allows multiple organ failure to further develop. 

COVID-19 necrotising pneumonia and extracorporeal membrane oxygenation: a challenge for anticoagulation

Abnormal coagulation parameters are associated with poor prognosis in patient with novel coronavirus pneumonia

Coagulation abnormalities and thrombosis in patients with COVID-19

Management of persistent pneumothorax with thoracoscopy and blebs resection in covid-19 patients