• COVID‐19 pneumonia
• bronchopleural fistula
• pneumothorax
• respiratory complications

• coronavirus disease
• coronavirus disease 2019
• pneumomediastinum
• pneumothorax
• prediction model

• bullous lung disease
• pneumothorax
• severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection

• COVID-19
• Pneumothorax
• SARS- COV-2

• COVID-19/complications
• Humans
• Mediastinal Emphysema/diagnostic imaging
• Mediastinal Emphysema/etiology
• Pandemics
• Pneumothorax/diagnostic imaging
• Pneumothorax/etiology
• SARS-CoV-2

• COVID-19
• Case report
• Emergency
• Pneumothorax
• Tension
• Thoracostomy

This case report describes a 60 year-old Black-American male with a past medical history of human immunodeficiency virus (HIV) infection and hyperthyroidism, who suffered a bilateral spontaneous pneumothorax (SP) in the setting of coronavirus disease 2019 (COVID-19) pneumonia. SP is a well-established complication in HIV-positive patients and only recently has been associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. While HIV and COVID-19 infections have been independently linked with increased risk of SP development, it is unknown if both infections interact in a synergistic fashion to exacerbate SP risk. According to the Centers for Disease Control and Prevention (CDC), patients living with HIV have a higher risk of developing severe COVID-19 infection and the mechanism remains to be elucidated. To the best of our knowledge, this is the first report of a HIV-positive patient, who in the setting of SARS-CoV-2 infection, developed bilateral apical spontaneous pneumothorax and was later found to have a left lower lobe tension pneumothorax. This case highlights the importance of considering SP on the differential diagnosis when HIV-positive patients suddenly develop respiratory distress in the setting of SARS-CoV-2 infection.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus, represents an unprecedented global threat. We report a 78-year-old male patient who presented to the Emergency Department at a tertiary care hospital in Muscat, Oman, in June 2020 with a one-day history of right chest pain and severe breathlessness. The patient was an ex-smoker and known to have idiopathic pulmonary fibrosis (IPF) with two previous pneumothoraces in the left lung. On presentation, the patient was breathless with an oxygen saturation of 90% on room air. Chest X-ray demonstrated bilateral lung infiltrates and right-sided pneumothorax. The patient tested positive for SARS CoV 2. A chest drain was placed which resulted in good resolution of the pneumothorax. The patient’s condition improved remarkably and he was discharged after 17 days of hospitalisation. To the best of the authors’ knowledge, this was the first case of pneumothorax reported in a patient infected with COVID-19 who was known to have underlying IPF.

• COVID-19
• Case Report
• Oman
• Oxygen
• Pleurodesis
• Pulmonary Fibrosis
• SARS Coronavirus
• Spontaneous Pneumothorax

• COVID-19
• Multi-detector computed tomography
• Pneumonia
• Pneumothorax
• Viral infections

Cases of spontaneous pneumothorax have been described in patients suffering from coronavirus disease 2019 (COVID-19) pneumonia. The aim of this study is to systematically review all the cases of spontaneous pneumothorax that occurred in healthy patients with no underlying lung disease and who did not receive invasive mechanical ventilation.

A PubMed research was conducted. The following data were collected: age, sex, side of the pneumothorax, smoking habit, time form onset of symptoms to the diagnosis of pneumothorax, the development of new bullous lesions on computed tomography and the type of treatment. In order to analyze the most homogeneous population possible, intubated patients were deliberately excluded. In total, 44 cases of spontaneous pneumothorax in otherwise healthy patients were taken into account. Since the available data were extracted from small observational studies, no particular bias risk assessment was performed. Descriptive statistics were used to synthesize results.

There were 37 male (84.1%) and 6 female (13.6%) patients. The majority of patients (66%) were treated only by chest tube thoracostomy, which most of the times resulted in a complete resolution of the pneumothorax. Simple surveillance was applied in 10 cases. Three patients underwent minimally invasive surgery. In 14 cases (31.8%) air-filled lesions were detected on imaging. Eleven patients received corticosteroids during their hospital stay. In the majority of cases (86.3%) the pneumothorax was resolved.

Even if the level of evidence, derived from case reports and small case series is low, the existence of a true secondary spontaneous pneumothorax due to SARS-CoV-2 should be recognized. Imaging techniques should be repeated throughout the clinical course of the patients in order to detect newly developed pulmonary complications. Surgical treatment is feasible and patients whose general condition permits, should be offered surgery according to the existing guidelines regarding spontaneous pneumothorax. National registries and databases are necessary in order to better understand the pathogenesis and complications of this novel entity.

• Coronavirus disease 2019 (COVID-19)
• pneumonia
• pneumothorax

The incidence of secondary coinfections particularly fungal infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not well described. Little is known of the complications that could be encountered in such conditions.

A 50-year-old Hispanic male who was a prior smoker presented with shortness of breath. He was diagnosed with SARS-CoV-2. He improved and was discharged with home oxygen. A month later, he presented with sudden onset cough and shortness of breath. Chest X-ray showed development of right-sided tension pneumothorax, right pleural effusion and an air-filled cystic structure. Computed tomography thorax showed findings suggestive of pulmonary coccidioidomycosis. Coccidioides antigen was positive, and fluconazole was initiated. For pneumothorax, a pigtail catheter was placed. The pigtail chest tube was later switched to water seal, unfortunately, the pneumothorax re-expanded. Another attempt to transition chest tube to water seal was unsuccessful. Pigtail chest tube was then swapped to 32-Fr chest tube and chemical pleurodesis was performed. This was later transitioned successfully to water seal and finally removed. He was discharged on a four-week oral course of fluconazole 400 mg and was to follow up closely as an outpatient for continued monitoring.

Pneumothorax is associated with a worse prognosis, especially with comorbidities such as diabetes, immunosuppression and malignancy. Suspicion for concomitant fungal infection in such patients should be high and would necessitate further investigation.

• SARS-CoV-2
• COVID-19
• Coccidioidomycosis
• Co-infection
• Fungal infection
• Tension pneumothorax
• Refractory pneumothorax
• Case report
• Literature review

Evaluation of pulmonary function impairment after COVID-19 in persistently symptomatic and asymptomatic patients of all disease severities and characterisation of risk factors.

Patients with confirmed SARS-CoV-2 infection underwent prospective follow-up with pulmonary function testing and blood gas analysis during steady-state cycle exercise 4 months after acute illness. Pulmonary function impairment (PFI) was defined as reduction below 80% predicted of DLCOcSB, TLC, FVC, or FEV1. Clinical data were analyzed to identify risk factors for impaired pulmonary function.

76 patients were included, hereof 35 outpatients with mild disease and 41 patients hospitalized due to COVID-19. Sixteen patients had critical disease requiring mechanical ventilation, 25 patients had moderate–severe disease. After 4 months, 44 patients reported persisting respiratory symptoms. Significant PFI was prevalent in 40 patients (52.6%) occurring among all disease severities. The most common cause for PFI was reduced DLCOcSB (n = 39, 51.3%), followed by reduced TLC and FVC. The severity of PFI was significantly associated with mechanical ventilation (p < 0.001). Further risk factors for DLCO impairment were COPD (p < 0.001), SARS-CoV-2 antibody-Titer (p = 0.014) and in hospitalized patients CT score. A decrease of paO2 > 3 mmHg during cycle exercise occurred in 1/5 of patients after mild disease course.

We characterized pulmonary function impairment in asymptomatic and persistently symptomatic patients of different severity groups of COVID-19 and identified further risk factors associated with persistently decreased pulmonary function. Remarkably, gas exchange abnormalities were revealed upon cycle exercise in some patients with mild disease courses and no preexisting pulmonary condition.

The online version contains supplementary material available at 10.1007/s15010-021-01669-8.

• COVID-19
• Post-COVID
• Pulmonary function impairment
• SARS-CoV-2

• COVID-19
• Pneumomediastinum
• Pneumothorax
• SARS-CoV-2

• ARDS
• COVID19
• ICU

• Aged
• COVID-19/complications
• COVID-19/diagnosis
• COVID-19/therapy
• Humans
• Intubation, Intratracheal/adverse effects
• Mediastinal Emphysema/diagnosis
• Mediastinal Emphysema/etiology
• Mediastinal Emphysema/therapy
• Pneumothorax/diagnosis
• Pneumothorax/etiology
• Pneumothorax/therapy
• Respiration, Artificial/adverse effects

The incidence of secondary pulmonary infections is not well described in hospitalized COVID-19 patients. Understanding the incidence of secondary pulmonary infections and the associated bacterial and fungal microorganisms identified can improve patient outcomes.

This narrative review aims to determine the incidence of secondary bacterial and fungal pulmonary infections in hospitalized COVID-19 patients, and describe the bacterial and fungal microorganisms identified.

We perform a literature search and select articles with confirmed diagnoses of secondary bacterial and fungal pulmonary infections that occur 48 h after admission, using respiratory tract cultures in hospitalized adult COVID-19 patients. We exclude articles involving co-infections defined as infections diagnosed at the time of admission by non-SARS-CoV-2 viruses, bacteria, and fungal microorganisms.

The incidence of secondary pulmonary infections is low at 16% (4.8–42.8%) for bacterial infections and lower for fungal infections at 6.3% (0.9–33.3%) in hospitalized COVID-19 patients. Secondary pulmonary infections are predominantly seen in critically ill hospitalized COVID-19 patients. The most common bacterial microorganisms identified in the respiratory tract cultures are Pseudomonas aeruginosa, Klebsiella species, Staphylococcus aureus, Escherichia coli, and Stenotrophomonas maltophilia. Aspergillus fumigatus is the most common microorganism identified to cause secondary fungal pulmonary infections. Other rare opportunistic infection reported such as PJP is mostly confined to small case series and case reports. The overall time to diagnose secondary bacterial and fungal pulmonary infections is 10 days (2–21 days) from initial hospitalization and 9 days (4–18 days) after ICU admission. The use of antibiotics is high at 60–100% involving the studies included in our review.

The widespread use of empirical antibiotics during the current pandemic may contribute to the development of multidrug-resistant microorganisms, and antimicrobial stewardship programs are required for minimizing and de-escalating antibiotics. Due to the variation in definition across most studies, a large, well-designed study is required to determine the incidence, risk factors, and outcomes of secondary pulmonary infections in hospitalized COVID-19 patients.

• Bacterial infection
• COVID-19
• Coronavirus disease 2019
• Fungal infection
• SARS-CoV-2
• Secondary infection
• Severe acute respiratory syndrome coronavirus 2
• Superimposed infection
• Superinfection

• COVID-19 pneumonia
• hemoptysis
• lung bulla

• Blister/diagnostic imaging
• Blister/etiology
• Blister/pathology
• COVID-19/complications
• COVID-19/diagnostic imaging
• COVID-19/pathology
• Cough/virology
• Fever/virology
• Hemoptysis/diagnostic imaging
• Hemoptysis/etiology
• Hemoptysis/pathology
• Humans
• Lung/diagnostic imaging
• Lung/pathology
• Male
• Middle Aged
• Pulmonary Alveoli/diagnostic imaging
• Pulmonary Alveoli/pathology
• SARS-CoV-2
• Tomography, X-Ray Computed

• COVID-19
• Corona virus
• Tension pneumothorax
• pneumomediastinum

Background and Objectives: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a viral disease that is spreading worldwide and became a pandemic. Although most of the time, the symptoms of the infection are flu like, a percentage of patients develop severe forms, along with severe complications. Many of them are known among front-line health workers, but the number of uncommon presentations and complications has increased. This case report aims to alert healthcare workers on less common forms of presentation, and to introduce this differential diagnosis in the evaluation of patients with COVID-19, given the increasing occurrence of pneumothorax in patients who are not mechanical ventilated. Case presentation: A 57-year-old female patient came to the Emergency Department (ED) by ambulance, with acute respiratory failure. She had SpO₂ (peripheral O₂ saturation ) = 43% on room air at home, and 86% on admission in ED after oxygen delivery (on a reservoir mask). SARS-CoV-2 infection was suspected based on symptoms that started three days ago (fever, dry cough, dyspnea, and fatigability). Blood was taken for lab tests, pharyngeal and nasal swabs for the reverse transcription–PCR (RT-PCR) test, and native computed tomography (CT) was scheduled. The thoracic CT scan showed massive right pneumothorax, partially collapsed lung, multiple bilateral lung infiltrates with a ground glass aspect and the RT-PCR test came back positive for SARS-CoV-2 infection. Despite the prompt diagnosis and treatment of pneumothorax (thoracostomy was performed and the drain tube was placed), the patient died after a long hospitalization in the intensive care unit. Conclusion: Secondary spontaneous pneumothorax (SSP), as a complication in severe forms of COVID-19 pneumonia, especially in female patients without risk factors is rare, and early diagnosis and treatment are essential for increasing the survival chances of these patients.

• COVID-19
• spontaneous pneumothorax
• thoracostomy during pandemia

• COVID-19/complications
• COVID-19/virology
• Female
• Humans
• Middle Aged
• Pneumothorax/virology
• SARS-CoV-2

A previously healthy 37-year-old man presented with fevers and myalgias for a week with a minimal dry cough. Initial SARS-CoV-2 nasopharyngeal testing was negative, but in light of high community prevalence, he was diagnosed with COVID-19, treated with supportive care and self-quarantined at home. Three days after resolution of all symptoms, he developed sudden onset chest pain. Chest imaging revealed a large right-sided pneumothorax and patchy subpleural ground glass opacities. IgM and IgG antibodies for SARS-CoV-2 were positive. His pneumothorax resolved after placement of a small-bore chest tube, which was removed after 2 days.

This case demonstrates that patients with COVID-19 can develop a significant pulmonary complication, a large pneumothorax, despite only minimal lower respiratory tract symptoms and after resolution of the original illness. Medical professionals should consider development of a pneumothorax in patients who have recovered from COVID-19 and present with new respiratory symptoms.

• adult intensive care
• pneumonia (infectious disease)
• pneumonia (respiratory medicine)
• pneumothorax

Data on patient-related factors associated with pneumothorax among critically ill patients with COVID-19 pneumonia is limited. Reports of spontaneous pneumothorax in patients with coronavirus disease 2019 (COVID-19) suggest that the COVID-19 infection could itself cause pneumothorax in addition to the ventilator-induced trauma among mechanically ventilated patients. Here, we report a case series of five mechanically ventilated patients with COVID-19 infection who developed pneumothorax. Consecutive cases of intubated patients in the intensive care unit with the diagnosis of COVID-19 pneumonia and pneumothorax were included. Data on their demographics, preexisting risk factors, laboratory workup, imaging findings, treatment, and survival were collected retrospectively between March and July 2020. Four out of five patients (4/5; 80%) had a bilateral pneumothorax, while one had a unilateral pneumothorax. Of the four patients with bilateral pneumothorax, three (3/4; 75%) had secondary bacterial pneumonia, two had pneumomediastinum and massive subcutaneous emphysema, and one of these two had an additional pneumoperitoneum. A surgical chest tube or pigtail catheter was placed for the management of pneumothorax. Three out of five patients with pneumothorax died (3/5; 60%), and all of them had bilateral involvement. The data from these cases suggest that pneumothorax is a potentially fatal complication of COVID-19 infection. Large prospective studies are needed to study the incidence of pneumothorax and its sequelae in patients with COVID-19 infection.

• Animals
• COVID-19/epidemiology
• COVID-19/virology
• Coinfection/epidemiology
• Coinfection/virology
• HIV/genetics
• HIV/physiology
• HIV Infections/epidemiology
• HIV Infections/virology
• Humans
• Pandemics
• SARS-CoV-2/genetics
• SARS-CoV-2/physiology

• Apnoea
• Breath-hold diving
• COVID-19
• Hypoxaemia
• Lungs
• SARS-CoV-2
• Scuba diving

As the global COVID-19 pandemic has progressed, awareness of uncommon presentations and complications has increased. The actual incidence of spontaneous pneumothorax was found to be 0.66%, or six patients out of 902 who tested positive in recently published literature of 3368 patients (Zantah M, Dominguez Castillo E, Townsend R, Dikengil F, Criner GJ. Pneumothorax in COVID-19 disease-incidence and clinical characteristics. Respir Res. 2020 Sep 16; 21 (1):236.). Of those six patients, only two (0.22%) were not associated with mechanical ventilation barotrauma or comorbid lung disease such as COPD. Here, we present a spontaneous pneumothorax and pneumomediastinum in a patient four days after he had been discharged from hospitalization due to uncomplicated COVID-19 pneumonia.

• COVID-19
• CT
• Case report
• Complication
• Coronavirus
• Pneumomediastinum
• SARS-Cov-2
• Spontaneous pneumothorax

• COVID-19 pneumonia
• pneumomediastinum
• pneumothorax
• tension pneumothorax

To our knowledge, Complications such as pneumomediastinum and/or pneumothorax during the course of COVID-19 remain rare and their mechanism is poorly described. We present a case of COVID-19 pneumonia associated with spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in an immunocompetent patient with no past history of smoking or chronic obstructive pulmonary disease (COPD). The only risk factor of this patient was prolonged cough. We hypothesize the mechanism underlying the pneumomediastinum is the aggressive disease pathophysiology in COVID-19 with an incresead risk of alveolar damage.

•

Complications such as pneumomediastinum and/or pneumothorax during the course of COVID-19 remain rare and their mechanism is poorly described.

• Coronavirus disease 2019
• emphysema
• pneumomediastinum
• pneumothorax
• severe acute respiratory syndrome coronavirus 2

Pneumothorax is a rare but life-threatening complication associated with pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Informed consent was obtained from the patient himself.A 50-year-old man presented with a 9-day history of fever, cough, and dyspnoea. He was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia and was admitted to the Medical Hospital, Tokyo Medical and Dental University. Chest CT showed diffuse patchy ground-glass opacities (GGOs). His state of oxygenation deteriorated, and mechanical ventilation was initiated on day 4 after admission (12th day from onset). He improved gradually and was weaned from ventilation on day 15. Sudden onset of bilateral pneumothorax occurred on day 21 with severe respiratory failure, and chest CT revealed pneumatocele formation on both lower lobes.

Pneumothorax is a notable complication in cases of severe COVID-19 pneumonia, especially in those who require positive-pressure ventilation.

• COVID-19
• COVID-19, coronavirus disease 2019
• CRP, C-reactive protein
• GGOs, ground-grass opacites
• P/F, PaO2/fraction of inspired oxygen
• PCR, polymerase chain reaction
• PEEP, positive end-expiratory pressure
• Pneumatocele
• Pneumonia
• Pneumothorax
• Positive-pressure ventilation
• SARS, severe acute respiratory syndrome
• SARS-CoV-2, severe acute respiratory syndrome coronavirus 2

• Aged
• Aged, 80 and over
• Anticoagulants/therapeutic use
• Betacoronavirus
• COVID-19
• Coronavirus Infections/diagnosis
• Coronavirus Infections/epidemiology
• Coronavirus Infections/therapy
• Extracorporeal Membrane Oxygenation/statistics & numerical data
• Female
• Humans
• Length of Stay
• Male
• Middle Aged
• Pandemics
• Pneumonia, Viral/diagnosis
• Pneumonia, Viral/epidemiology
• Pneumonia, Viral/therapy
• Prognosis
• Prone Position
• Respiration, Artificial/statistics & numerical data
• Retrospective Studies
• Risk Factors
• SARS-CoV-2
• Tokyo/epidemiology
• Treatment Outcome

• Adult
• Betacoronavirus
• COVID-19
• Coronavirus Infections/complications
• Female
• Humans
• Male
• Mediastinal Emphysema/etiology
• Middle Aged
• Pandemics
• Pneumonia, Viral/complications
• Pneumothorax/etiology
• SARS-CoV-2

The most dreaded thoracic complications in patients with coronavirus disease 2019 (COVID-19) are acute pulmonary embolism and pulmonary fibrosis. Both the complications are associated with an increased risk of morbidity and mortality. While acute pulmonary embolism is not a rare finding in patients with COVID-19 pneumonia, the prevalence of pulmonary fibrosis remains unclear. Spontaneous pneumothorax is another possible complication in COVID-19 pneumonia, although its observation is rather uncommon. Herein, we present interesting computed tomography images of the first case of COVID-19 pneumonia that initially developed acute pulmonary embolism and subsequently showed progression toward pulmonary fibrosis and spontaneous pneumothorax.

• COVID-19
• acute pulmonary embolism
• computed tomography
• pneumothorax
• pulmonary fibrosis

In the coronavirus disease 2019 (COVID-19) era, the presence of acute respiratory failure is generally associated with acute respiratory distress syndrome; however, it is essential to consider other differential diagnoses that require different, and urgent, therapeutic approaches. Herein we describe a COVID-19 case complicated with bilateral spontaneous pneumothorax. A previously healthy 45-year-old man was admitted to our emergency department with sudden-onset chest pain and progressive shortness of breath 17 days after diagnosis with uncomplicated COVID-19 infection. He was tachypneic and presented severe hypoxemia (75% percutaneous oxygen saturation). Breath sounds were diminished bilaterally on auscultation. A chest X-ray revealed the presence of a large bilateral pneumothorax. A thoracic computed tomography (CT) scan confirmed the large bilateral pneumothorax, with findings consistent with severe COVID-19 infection. Chest tubes were inserted, with immediate clinical improvement. Follow-up chest CT scan revealed resolution of bilateral pneumothorax, reduction of parenchymal consolidation, and formation of large bilateral pneumatoceles. The patient remained under observation and was then discharged home. Bilateral spontaneous pneumothorax is a very rare, potentially life-threatening complication in patients with COVID-19. This case highlights the importance of recognizing this complication early to prevent potentially fatal consequences.

• Bilateral spontaneous pneumothorax
• COVID-19
• SARS-CoV-2
• Spontaneous pneumothorax