Melioidosis, endemic in Southeast Asia and Northern Australia, is an uncommon but frequently fatal opportunistic infection caused by the Gram-negative saprophyte Burkholderia pseudomallei. We describe the first reported case of activation of latent melioidosis concurrent with COVID-19-associated lymphopenia and neutropenia in the setting of poorly controlled diabetes. A 43-year-old HIV-positive, diabetic man presented to the emergency department with persistent chills and progressive dyspnea. He was admitted for hypoxia. Chest X-ray showed bilateral parenchymal infiltrates suspicious for COVID-19. Shortly after admission, he became acutely encephalopathic, had a generalized seizure, and was transferred to the intensive care unit after intubation. Further workup showed severe neutropenia and lymphopenia. The patient received empiric antimicrobial coverage and was found to be severe acute respiratory syndrome coronavirus 2 positive. He deteriorated rapidly with refractory shock and persistent hypoxemia, and died 40 hours after admission. Blood cultures and sputum cultures obtained via bronchoalveolar lavage returned positive for Burkholderia pseudomallei. Given confirmed compliance with antiretrovirals, stable CD4 counts, and no recent foreign travel, the patient likely contracted the B. pseudomallei infection from travel to Southeast Asia many years prior and only became symptomatic after succumbing to severe acute respiratory syndrome coronavirus 2 infection. This case highlights the importance of considering activation of latent opportunistic infections by COVID-19 in immunocompromised patients.

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Pneumomediastinum is a rare complication among non-coronavirus patients but has been published with increased incidence in patients positive for SARS-CoV-2 infection. Most of these studies report patients on mechanical ventilation and an understanding of mechanisms causing this remains limited. We aim to use an increasing occurrence in patients not on mechanical ventilation to further explore mechanisms that predispose patients to pneumomediastinum and to assess characteristics potentially related to poor outcomes. We report a case series of 37 patients diagnosed with COVID-19 and pneumomediastinum at a 2-hospital institution between January 1, 2020 and April 30, 2021. At 28 days after diagnosis of pneumomediastinum, 19 (51.4%) were dead and mortality was significantly higher among those who were older ( t = 2.147, P = .039), female (χ2 = 10.431, P = .015), body mass index ≥30 (χ2 = 6.0598, P = .01), intubated (χ2 = 4.937, P = .026), and had pre-existing lung disease (χ2 = 4.081, P = .043). Twenty-three patients (62.2%) were identified to have pneumomediastinum without receiving invasive mechanical ventilation, of which 11 (47.8%) were diagnosed without receiving noninvasive ventilation. The increased diagnosis of pneumomediastinum in patients with COVID-19 while not on mechanical ventilation, in this case series and in comparable studies, may attribute to mechanisms aside from positive pressure ventilation such as patient self-induced lung injury and pulmonary frailty.