Spontaneous Pneumothorax as Unusual Presenting Symptom of Covid-19 Pneumonia: Surgical Management and Pathological Findings

Abstract

Spontaneous pneumothorax has been reported as a possibile complication of novel coronavirus associated pneumonia (COVID-19). We report two cases of COVID-19 patients who developed spontaeous and recurrent pneumothorax as a presenting symptom, treated with surgical procedure. Intraoperative findings of COVID-19 pneumonia were parenchymal atelectasis and vascular congestion. Lung tissue was very frail and prone to bleeding. Histological examination showed interstitial infiltration of lymphocytes and plasma cells, as seen in non specific interstitial pneumonia, together with myo-intimal thicknening of vessels with blood extravasation and microthrombi. Lung surgery for pneumothorax in COVID-19 patients can be safely and effectively performed when necessary.

Pneumothorax/pneumomediastinum and pre-existing lung pathology in ventilated COVID-19 patients: a cohort study

“…A reasonable explanation for the air escape is offered by the localised vascular necrosis of the external layer of the coat of the lung. The surgical finding of one of the resected bullae being rotten (23) supports this hypothesis. Venous micro thrombosis, capillary wall thickening is a proven consequence of COVID-19 infection, a phenomenon leading to wet necrosis, hence the cited rotten bulla.…”

Spontaneous pneumothorax, with or without pulmonary cysts, in patients with COVID-19 pneumonia

“…Proposed mechanisms of cystic lung disease include necrosis due to ischemia, remodeling of interstitial matrix, and bronchial obstruction with distal hyperinflation phenomenon due to a check-valve mechanism. Histopathologic features of COVID-19 may help to understand the mechanism of pneumothorax and cystic lesions; reports of autopsies have showed lung injury consistent with early acute respiratory distress syndrome as the main finding, followed by acute fibrinous and organizing pneumonia, microthrombi, vascular congestion and necrosis with microvascular damage [6,15]. Ischemia due to microvascular damage and exudates causing a checkvalve mechanism within airspaces could be involved in cysts formation [9].…”

Tension Pneumothorax With Persistent Air Leak in Critical COVID-19 Pneumonia With Acute Respiratory Distress Syndrome Treated With Intrabronchial Valves

“…Loculated pneumothoraces and the presence of multiple ipsilateral or bilateral pneumothoraces associated with pneumomediastinum have been described in several case reports and case series of COVID-19 patients. 6,8 Our case is unique in that our patient developed recurrent tension pneumothorax despite having a functioning ipsilateral chest tube, indicating that loculated pneumothoraces can still be life-threatening.…”

“…4,5 Similarly, distal bullous emphysematous changes have been described as intraoperative findings in patients who underwent thoracic surgery for management of pneumothorax. 6,7 Further, lung infarction may produce cavitary lesions that can rupture and lead to pneumothorax. Finally, barotrauma in ventilated patients has been proposed as a mechanism, but is unlikely to be the sole factor as pneumothorax has been reported in spontaneously breathing patients.…”