Spontaneous massive hemothorax as a complication of necrotizing pneumonia in a patient with severe acute respiratory syndrome coronavirus 2 induced acute respiratory distress syndrome: a case report

Abstract

Background We present an unusual bleeding complication in a patient with severe acute respiratory distress syndrome in coronavirus disease 2019. Case presentation The patient, a 63-year-old Caucasian man, received venovenous extracorporeal membrane oxygenation support after rapid deterioration of lung function on day 6 after admission to hospital. After initial stabilization on lung protective ventilation and prone positioning, he started to develop mild bleeding complications until he went into occult profound hemorrhagic shock. Causative was a massive hemothorax of the right hemithorax with mediastinal shifting due to spontaneous bleeding from a pulmonal artery in a heavily remodeled right inferior lobe. Histopathological examination of the resected tissue showed signs of an organizing fibrinous pneumonia with focal parenchyma necrosis. After surviving a massive bleeding event caused by necrotizing pneumonia, the patient made a swift recovery and was discharged to rehabilitation 31 days after initial hospital admission. Conclusions The combination of severely elevated inflammatory markers and pulmonary hemorrhage should arouse suspicion of necrotizing pneumonia. In necrotizing pneumonia, the possibility of severe intrathoracic bleeding complications should be kept in mind if it comes to sudden deterioration of the patient.

Spontaneous Haemothorax in a Patient with COVID-19

“…Our patient also showed no evidence of necrotising pneumonia or bullae rupture, two other well described causes of spontaneous haemothorax in patients with COVID-19 reported by Jung et al and Brogna et al, respectively [4,9].…”

“…Vascular pathologies, necrotising infections, connective tissue disorders, pleural diseases, malignancy, and bleeding disorders are some causes of spontaneous haemothorax [ 7 ]. Postulated causes of haemothorax in COVID-19 include pulmonary artery aneurysm [ 6 ], barotrauma [ 8 ], and necrotising pneumonia [ 9 ].…”

An abrupt fatal hemothorax in a stable COVID-19 patient: a case report with literature review

“…Later on, the patient had an abrupt massive hemothorax and developed signs of shock. Prompt management of the patient led to an uneventful recovery and the patient was discharged eventually 5 . A similar case of a 68-year-old patient with severe necrotizing pneumonia on VV-ECMO had sudden left hemothorax that led to a fatal refractory shock and multiple organ systems failure 9 .…”

“…Hemothorax is one of the rarest severe forms of hemorrhagic complications associated conclusively with severe cases. Only few reports have been published regarding COVID-19 associated hemothorax; all of the cases were associated with severe infections, and most of the patients were even on VV-ECMO 3 – 5 , 8 , 9 .…”

“…Hemothorax is one of the rarest reported complications of COVID-19 in the medical literature; there are only few reports regarding this complication 3 – 5 . Spontaneous hemothorax associated with COVID-19 patients is reported exclusively in association with severe infection and mostly with veno-venous extra corporeal membrane oxygenation (VV-ECMO).…”