key: cord-0994089-m7tenozr
authors: Sahu, Kamal Kant; Mishra, Ajay Kumar; Goldman, Yaron
title: n“A rare case of Pneumopericardium secondary to COVID-19”
date: 2020-08-21
journal: Heart Lung
DOI: 10.1016/j.hrtlng.2020.08.017
sha: 2c073d3e28d4b9f13a23d75d04119798c3dbda11
doc_id: 994089
cord_uid: m7tenozr

Coronavirus disease 2019 (COVID-19) has posed an unparalleled challenge to the medical communities and patients worldwide (1). This is the third coronavirus pandemic of the decade and worst so far in terms of the number of days which was affected and related deaths. Although COVID-19 is a systemic illness, the respiratory system is obvious to be involved first, and takes most of the brunt of SARS-CoV-2 infection(2). Common upper and lower respiratory presentation could be sore throat, consolidation, ground glass opacities, and acute respiratory distress syndrome in severe cases. Pneumothorax, pneumomediastinum are uncommon clinical findings in association with COVID-19. We hereby report a rare case of spontaneous pneumomediastinum with a synchronous pneumopericardium.

room, his vitals were: Temperature 100.8 F, pulse 90/min, blood pressure 147/80 mmHg, Respiratory rate 19/min, SpO2 96% on 2 liters O2 through nasal canula. Chest X ray showed bilateral peripheral patchy airspace opacities ( Figure 1A ). Suspecting COVID-19 pneumonia, he was put in airborne and contact precaution. His laboratory tests showed a C-reactive protein concentration of 136 mg/L (normal range 0·00-4.9] mg/L), D-dimer value-2.90 mg/L (<0.5 mg/L), serum ferritin-2539 ng/ml (30-400) . Complete blood count showed elevated leukocytes (11,400 cells per μL [normal range 3900-1100 per μL]), lymphocyte count 900 [ 700-4500 cells per μL]). His nasopharyngeal swab for RTPCR for COVID-19 was sent which came back positive. Patient gradually started deteriorating with worsening hypoxia, increased work of breathing and requiring high level of oxygen. He was given Remdesevir for 5 days and one unit of plasma therapy. The patient was also tested for other respiratory viruses like influenza A and B viruses, respiratory syncytial virus which were negative. On day 7 of hospital stay, patient started worsening acutely with increase work of breathing. He was switched from high flow to BiPAP to support for his worsening breathing efforts and hypoxia. A repeat CXR shows pneumomediastinum and pneumopericardium ( Figure 1B ).

Patient continued to have worsening breathlessness, and some chest discomfort. Clinical

Examination also suggested evidence of subcutaneous emphysema. A decision was made to intubate the patient and a repeat chest X ray showed mild resolution of pneumomediastinum ( Figure 1C ). Patient subsequently had followed up imaging studies which showed resolution of the pneumomediastinum and pneumopericardium ( Figure 1D ). He received tocilizumab therapy Spontaneous pneumopericardium is rarer than pneumomediastinum and so far, has not been reported in COVID-19. In past, individuals report of pneumopericardium after Whipple Procedure, thymic surgery, and lung transplantation (6) (7) (8) . Drug abusers are exposed to variety of complications related to cardiovascular and pulmonary system (9, 10) . An interesting case of spontaneous pneumopericardium secondary to cannabinoid hyperemesis syndrome (11) .

Our case endorses for the fact that any acute worsening in the clinical picture of the patient with rapid oxygen desaturation in a COVID-19 patient should be thoroughly evaluated and possibility of spontaneous pneumothorax, pneumomediastinum, and pneumopericardium should be considered n addition to other common differentials like worsening pneumonia, flash pulmonary edema, and cardiac tamponade (14). Figure 1A . Chest X ray showing bilateral peripheral patchy airspace opacities 

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