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.