Spontaneus pneumomediastinum and subcutaneus emphysema in nonventilated COVID-19 patient
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Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Poland
Beata Moczulska   

Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30, 10-082 Olsztyn, Poland. Tel.: +4889 524 53 87.
Submission date: 2022-03-24
Final revision date: 2022-08-10
Acceptance date: 2022-08-11
Online publication date: 2022-09-09
The most common complications of COVID-19 infection are: pneumonia, acute respiratory distress syndrome, pulmonary fibrosis, pulmonary embolism, pneumothorax and pneumomediastinum.

We would like to highlight the rarity of pneumomediastinum and subcutaneous emphysema in nonventilated COVID-19 patient.

Case study:
A 50-year-old man was addmitted to the COVID-19 Department with SARS-CoV-2 pneumonia. The patient wasn’t vaccinated against COVID- 19. Upon admission the general condition was quite good with mild dyspnea.

Results and discussion:
Upon admission a CT scan was performed in which there were bilateral infiltrates consistent with COVID-19 infection, covering approximately 50% of the lungs. On the 5th day of hospitalization the general condition deteriorated and a drop in saturation was observed. A follow-up CT scan revealed progression of lung inflammatory changes that spanned approximately 60%–70% of lung parenchyma; there was pneumomediastinum and subcutaneous emphysema in the neck, left subclavian, and axillary area. High flow nasal oxygen therapy (60 L/min) was administered. On the 13th day the general condition of the patient further deteriorated and blood saturation continued to drop which prompted the decision to escalate treatment. Initially, noninvasive ventilation was used, however, shortly after the patient was intubated. Immediately after intubation the patient went into cardiac arrest that ultimately led to his death.

The development of spontaneus pneumomediastinum in the patient can be mainly attributed to the intense cough and rapidly developing acute respiratory distress syndrome in the course of SARS-CoV-2 infection despite aggressive treatment with steroids, tolicizumab, and antibiotics for staphylococcal pneumonia.

We would like to thank the COVID-19 Department in University Clinical Hospital in Olsztyn for contribution in getting patient’s data and images.
This manuscript is not funded by any organization.
No conflict of interest.
Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med. 1984;144(7):1447–1453.
Murayama S, Gibo S. Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography. World J Radiol. 2014;6(11):850–854.
Romaszko-Wójtowicz AM, Doboszyńska A. Pulmonary complications due to COVID-19 – a literature review. Pol Ann Med. 2021;28(2):244–249.
Onuki T, Ueda S, Yamaoka M, et al. Primary and Secondary Spontaneous Pneumothorax: Prevalence, Clinical Features, and In-Hospital Mortality. Can Respir J. 2017;2017:6014967.
Chu CM, Leung YY, Hui JYH et al. Spontaneous pneumomediastinum in patients with severe acute respiratory syndrome. Eur Respir J. 2004;23(6):802–804.
Vazzana N, Ognibene S, Dipaola F. Pneumomediastinum and subcutaneous emphysema after noninvasive ventilation in a COVID-19 patient. Adv Respir Med. 2020;88(5):466–467.
Peiris JSM, Chu CM, Cheng VCC. Clinical progression and viral load in a community outbreak of coronavirus associated SARS pneumonia: a prospective study. Lancet. 2003;361(9371):1767–1772. https://10.1016/s0140-6736(03)....
Hsiao CH, Wu MZ, Hsieh SW, et al. Clinicopathology of severe acute respiratory syndrome: an autopsy case report. J Formos Med Assoc. 2004;103(10):787–792.
Meireles J, Neves S, Castro A, França M. Spontaneous pneumomediastinum revisited. Respir Med CME. 2011;4(4):181–183.
Gorospe L, Ayala-Carbonero A, Ureña-Vacas A, et al. Spontaneous Pneumomediastinum in Patients With COVID-19: A Case Series of Four Patients. Arch Bronconeumol. 2020;56(11):754–756.
Yates SP, Morcos SK. Delayed tension pneumothorax complicating staphylococcal pneumonia. Postgrad Med J. 1988;64(756):796–798.
Finnie IA, Jack CI, McKay JS. Pneumomediastinum and subcutaneous emphysema complicating staphylococcal pneumonia. Ulster Med J. 1995;64(1):105–107.
Sihoe AD, Wong RH, Lee ATH, et al. Severe acute respiratory syndrome complicated by spontaneous pneumothorax. Chest. 2004;125(6):2345–2351.
Hui DS, Sung JJ. Severe acute respiratory syndrome. Chest. 2003;124(1):12–15.
Ro S, Nishimura N, Imai R, et al. Identification of patients with COVID-19 who are optimal for methylprednisolone pulse therapy. Multidiscip Respir Med. 2021;16(1):781.
Zhou C, Gao C, Xie Y, Xu M. COVID-19 with spontaneous pneumomediastinum. Lancet Infect Dis. 2020;20(4):510.