Rare combination of pneumothorax, pneumomediastinum and pneumopericardium and a bronchopleural fistula in Covid-19

A 78-year-old man presented with a one-week history of worsening shortness of breath and cough. On examination, he had obvious respiratory distress and was profoundly hypoxic, requiring high-flow oxygen. Chest radiography revealed severe consolidation in both lung fields. Covid-19 was confirmed by SARS-CoV-2 detection in nasopharyngeal and oropharyngeal swab samples using RT-PCR. Intravenous corticosteroids, immune modulators, and therapeutic anticoagulants were initiated. However, the patient required ongoing high-flow oxygen to maintain oxygen saturation. Computed tomography (CT) of the thorax revealed groundglass opacities in both lung fields with a right pneumothorax, pneumopericardium, and pneumomediastinum, and a bronchopleural fistula. The patient was treated conservatively owing to his frailty. He was discharged from hospital to palliative care. Bronchopleural fistulas, which cause spontaneous pneumothorax, pneumomediastinum, and pneumopericardium, are rare complications of Covid-19. They can occur because of the overwhelming cytokine storm leading to alveolar rupture and air dissects through the peribronchial vascular sheath into the mediastinum and pericardium. The patient developed a spontaneous pneumothorax, pneumomediastinum, and pneumopericardium, despite not receiving positive pressure ventilation. To our knowledge this triple combination has not been reported previously in Covid-19. It is important to recognize that they may occur in the absence of positive pressure ventilation. Currently, there are no official guidelines for managing these complications in the context of Covid-19. Several patients have been treated conservatively with good outcomes; however some patients require surgical intervention. Further reports are required to obtain further evidence on the management of these complications. (author)