Case report:
A 40-year-old non-smoker, previously healthy gentleman, presented with
worsening shortness of breath and sore throat for a few days. A chest
x-ray showed bilateral airspace patchy opacities suggestive of pneumonia
(figure 1-A). Polymerase Chain Reaction (PCR) from a nasopharyngeal swab
was positive for SARS-CoV-2. On admission, the patient was afebrile, but
tachypneic and required continuous positive airway pressure therapy
(CPAP) alternating with 50 liters of high flow nasal canula of oxygen to
maintain his oxygen saturation around 92%. The patient was admitted
into the intensive care unit as a case of severe COVID-19 pneumonia. He
was treated according to the local COVID-19 protocol including
methylprednisolone, remidisivir, azithromycin, tocilizumab and
intravenous immunoglobulin. The patient did not require intubation nor
central line insertion during hospitalization.
Three weeks after admission, the patient was suffering from rapid
worsening of shortness of breath, using accessory respiratory muscles,
and required higher levels of oxygen. Chest X-ray showed right-sided
tension pneumothorax with collapsed right lung and pushed heart and
mediastinum to the left side (figure 1-B). A chest tube was urgently
inserted with a remarkable improvement of breathlessness and oxygen
saturation (figure 1-C). Chest CT scan showed bilateral diffuse
ground-glass opacities, moderate right-sided pneumothorax, minimal
right-sided pleural effusion, and right chest tube seen in-situ (figure
1-D). However, it did not show any underlying emphysema or bullae. Over
the next few days, the chest tube was kept in place to give time for
healing. However, it was continuously bubbling for the next three weeks.
Gathering the above findings, the picture suggested that a
bronchopleural fistula is the reason behind the persistent air leak.
Given the unstable lungs’ condition, the patient was not fit for a
surgical intervention at that point. Therefore, the decision was to keep
the chest tube as long as possible or to discharge him with Hemlich
valve waiting for spontaneous recovery or possible surgical intervention
once he is medically fit.
The chest tube was incidentally removed on day 42 post-insertion, then
the pneumothorax reaccumulated while the patient clinically remained
stable (figure 2-A). A right intercostal pigtail catheter was inserted
in the 2nd intercostal space into the mid-clavicular line. On day 52
post chest tube insertion (10 days later), the chest tube had showed no
more bubbling for 2 days, So the pigtail catheter was removed. The
patient was discharged after 3 days of observation (figure 2-B). The
patient had a follow-up phone call after one week which demonstrated no
active complaints.