SPONTANEOUS PNEUMOMEDIASTINUM IN PATIENTS WITH COVID-19. CASE REPORT

1 Departamento de Medicina Interna, Hospital Nacional Edgardo Rebagliati Martins, Essalud, Lima-Perú. 2 Departamento de Cirugía de Tórax y Cardiovascular, Hospital Nacional Edgardo Rebagliati Martins, Essalud, Lima-Perú. 3 Departamento de Radiología, Hospital Nacional Edgardo Rebagliati Martins, Essalud, Lima-Perú. a Specialist in Internal Medicine. b Chest Surgery Specialist Physician. c Specialist in Interventional Radiology. Cite as: Pedro Paolo Sotelo-Jiménez, Enrique Moyano Navarro, Félix Tipacti Rodríguez, Carlos Milla Bravo. Spontaneous Pneumomediastinum in a patient with COVID-19: Case report. Rev. Fac. Med. Hum. April 2021; 21(2)440-443 DOI 10.25176/RFMH.v21i2.3651 ABSTRACT


INTRODUCTION
Spontaneous pneumomediastinum (SPM) or Hamman's syndrome is a secondary complication to increased intra-alveolar pressure that causes alveolar rupture and air outflow from the bronchial tree to the mediastinum (1) , which in turn can spread to the subcutaneous tissue, exceptionally at the endothoracic and peritoneal levels, or even to the spinal canal (1,2) .
It was first described in 1939 as a very characteristic but infrequent sign consisting of crepitus concomitant with the heartbeat and is perceived during auscultation of the anterior thoracic region (Hamman's sign) (3) . The predisposing conditions which have been described are interstitial pulmonary and chronic obstructive diseases, bronchial asthma, bronchiectasis, trauma and thoracic procedures, mechanical ventilation, inhaling toxic substances, foreign body, chesty cough, labor and lung cancer. The probability to develop such pathology is a consequence of respiratory infections with severe cough as it is in the case of infection by coronavirus SARS-CoV-2 (2,4) .

CLINICAL CASE
A 43-year-old male patient from Lima with a history of overweight. He denied tobacco use and previous pulmonary diseases. He was in direct epidemiological contact five days prior with his brother who had been infected by coronavirus. He presented a 15-day illness characterized by pharyngeal pain, general discomfort, moderate frontoparietal cephalea, fever, anosmia and ageusia. He received ambulatory treatment with multiple schemes: clarithromycin, hydroxychloroquine, ivermectin, levofloxacin (stopped due to allergic reaction) and intravenous ceftriaxone without clinical response until he developed chest pain, lingering cough with greenish sputum and progressive respiratory distress four days prior to hospital admission. Due to this, he attended the emergency department at CELIM -Hospital Nacional Edgardo Rebagliati Martins (HNERM) reaching oxygen saturation (Sat02) at 86%. It was initially diagnosed as acute respiratory failure and atypical pneumonia caused by COVID-19 requiring oxygen therapy by mask with a reservoir bag. There was no history of invasive procedures in the thoracic area. Blood cultures for common germs were negative for bacterial growth.
The chest tomography scan showed areas of alveolar infiltrate in frosted glass, bilateral consolidation with 50% pulmonary compromise, as well as subcutaneous emphysema and pneumomediastinum (Figure 1 and 2).
Upon medical assessment by the Thoracic Surgery Department, it was concluded he did not require a special surgical procedure and only conservative management and observation was needed.
He was given 250 mg of methylprednisolone every 24 hours for 5 days, 60 mg of enoxaparin subcutaneously every 24 hours, 4.5 g of piperacillin/ tazobactam intravenously every 6 hours for 10 days, progressive weaning of oxygen therapy and strict monitoring of oxygen saturation.
He progressed favorably and his medical controls two weeks after showed gas disappearance in soft tissues at cervical and mediastinum levels, bilateral evolutive consolidations ( Figure 3A and 3B).

DISCUSIÓN
Pneumomediastinum is an infrequent and rare pathology with an incidence of 1:44000 hospital admissions. It is over 70% more frequent in young males, generally originating from air migration from the ruptured alveoli to the mediastinum through the Macklin effect6. The typical radiological manifestations in patients with SARS-CoV-2 pneumonia consist of the presence of bilateral ground-glass pulmonary opacities, peripheral distribution, consolidations and pulmonary thromboembolism in some cases5.
In this case, our patient used several drugs (antimicrobials) on an outpatient basis with no proven efficacy at the present time. According to a meta-analysis, only 3.5% of patients present bacterial co-infection at the time of admission while 15% of them present it during hospital stay, and more than 71% were prescribed antibiotics, all of which generates bacterial resistance, adverse reactions and unnecessary costs7 as a consequence.
A recent series of patients with COVID-19 indicates that 1% of patients can develop spontaneous pneumomediastinum as a complication (8) and, although the exact mechanism by which spontaneous pneumomediastinum occurs in SARS-CoV-2 pneumonia is unknown, it is attributed to intense coughing or valsalva maneuvers. In theory, it is considered a self-limited and benign condition which responds favorably to conservative therapeutic measures in most cases (7) , but it requires observation and continuous follow-up when there is a predisposing pulmonary disease due to the possibility of related cardiovascular and respiratory complications. Therefore, further research is needed to determine its prognostic significance and, in case it becomes a marker of disease progression in COVID-19 infection, measures or specific recommendations (4,7) should be established.

CONCLUSION
This case report stresses the pulmonary complications to be considered in patients infected by COVID-19, such as bilateral pneumonia, bacterial coinfection, sepsis, respiratory failure and spontaneous pneumomediastinum. The treatment for this last mentioned is observation and continuous monitoring, especially in patients who show disease progression.