ISSN: 0000-0000

Published 00 1111 00

OPEN ACCESS

Edited by

A.Hussain

Submitted 14 oct 2021

Accepted 2 Nov 2021

Citation

Mohd Shahimin ,Nor

Safariny A.Spontaneous

PneumothoraxMimicking

PerforatedViscusinCovid-

19patien.BJOSS.2021:1(1)8-

Spontaneous Pneumothorax Mimicking

Perforated Viscus in Covid-19 patient

Mohd Shahimin S

and Nor Safariny A

Department of Surgery, Hospital Putrajaya, Putrajaya, Malaysia. Email:

shahimin89@gmail.com

O R IGI N A L

Abstract

Introduction: Spontaneous pneumothorax is an uncommon complication of COVID-19 viral

pneumonia. We reviewed a case of spontaneous pneumothorax mimicking perforated viscus in

COVID-19, which was managed non-surgically.

Case presentation: A 65-year-old female diagnosed with COVID-19 developed worsening respira-

tory distress requiring invasive ventilation. Chest radiography post-intubation revealed air under

the diaphragm, pneumomediastinum and subcutaneous emphysema. Case was referred to surgical

team for emergency laparotomy for suspected perforated viscus. Clinically, her abdomen was

distended but there was no sign of peritonism. In view of high risk of perioperative morbidity and

absent of peritonism, CT scan was done to rule out cause of pneumoperitoneum. CT scan showed

bilateral pneumothorax, presence of air in extra peritoneum and retroperitoneum. There was no

air in the peritoneum and no evidence of perforated viscus. She was treated conservatively with

bilateral chest tube insertion. Unfortunately, she developed multiorgan failure and succumbed to

death.

Discussion: This case demonstrates that COVID-19 patient can develop a large pneumothorax

which presented with subcutaneous emphysema, pneumomediastinum and pneumoperitoneum

mimicking perforated viscus. Spontaneous pneumomediastinum is a rare condition that occurred

when alveolar rupture, followed by air dissection through bronchovascular sheath into the medi-

astinum. The passage of air from the thorax to the abdomen can occur due to the presence of

anatomical oriﬁces, especially in the weak areas of the diaphragm such as the posterolateral and

parasternal area.

Conclusion: The diagnostic suspicion of non-surgical pneumoperitoneum in a COVID-19 patient

is essential as it may lead to unnecessary laparotomy. This entity required thorough clinical and

radiological evaluation because wrong diagnosis can cause perioperative morbidity and mortality.

keywords: COVID-19, Pneumothorax, Subcutaneous emphysema, Pneumoperitoneum

Introduction

The Coronavirus disease 2019 (COVID-19) was identiﬁed on January 6, 2020 and was term 2019-

nCOV. It was originated in bats and was transmitted from human to human in Huanan Seafood

Market, Wuhan in late December 2019 (

). It had since infected more than 175 mil lion individuals

globally and approximately more than 650,000 individuals in Malaysia (

). The clinical features

of COVID-19 are varied, ranging from asymptomatic to acute respiratory distress and can lead

to multiorgan failure. Spontaneous pneumothorax is an uncommon complication of COVID-19

viral pneumonia. The exact risk factors and incidence are still unknown (

). We described a case

of spontaneous pneumothorax mimicking perforated viscus in COVID-19, which was managed

non-surgically.

Case presentation

63 years old female with a history of hypertension and type 2 Diabetes Mellitus presented with a

week history of a chesty cough, lethargy and fever. Upon presentation, she was febrile, tachyp-

neic, tachycardic and hypoxic requiring oxygen supplement via nasal prongs 3L per minutes. Her

pulmonary examination revealed bibasal crepitation more on the right side of her lungs. Her

blood work was concerning for lymphopenia and increased inﬂammatory markers. Absolute

Lymphocyte counts (ALC) showed low in value (0.36). Chest radiography (CXR) showed consoli-

dation of the bilateral lower zone Figure 1. She was diagnosed with COVID-19 disease based

on PCR nasopharyngeal swab. She was started on an antibiotic (Piperacillin/Tazobactam) and

corticosteroids (Dexamethasone). The patient was noted to be more tachypneic and hypoxic

three days later. Blood gases done showed Type I Respiratory failure. She was intubated due to

worsening respiratory acidosis and connected to mechanical ventilation. Post intubation CXR

revealed the presence of air under the diaphragm, subcutaneous emphysema and pneumomedi-

astinum Figure 2. Her abdomen was soft, non-tender, non-distended with normoactive bowel

sounds. Clinically there was no sign of peritonism. Our surgical team was consulted to rule out

perforated viscus in view of massive pneumoperitoneum.

Figure 1. CXR on admission revealed consolidation of bilateral lower zone

Figure 2. CXR post intubation showed presence of air under diaphragm,subcutaneous

emphysema and consolidation of bilateral lung ﬁeld.

In view of high risk for laparotomy and absent of peritonism, CT scan was done to rule out non-

9/13

surgical cause of pneumoperitoneum. CT scan of thorax, abdomen and pelvis showed extensive

subcutaneous emphysema over the chest extending to the anterior abdomen, shoulder, neck and

back. Presence of bilateral pneumothorax and pneumomediastinum with diﬀuse glass densities

and patchy consolidation in both lungs. Air was seen extending into the extra-peritoneum and

retroperitoneum. However, no free ﬂuid was seen in the abdomen, pelvis and no leak of contrast

was seen Figure 3 Figure 4. A decision was made to treat the patient conservatively due to the

absence of evidence of viscus perforation clinically and radiologically.

Figure 3. Extensive subcutaneous emphysema over the chest (more on right sided) extending

into extra-peritoneum and retroperitoneum.

Figure 4. Extensive subcutaneous emphysema over the chest (more on right sided) extending

into extra-peritoneum and retroperitoneum.

A bilateral chest tube was inserted via an open approach and connected to the underwater seal in

a usual manner. CXR post chest tube insertion showed resolved air under the diaphragmFigure 5.

10/13

Figure 5. CXR post bilateral chest tube showed resolved air under diaphragm and resolving

subcutaneous emphysema.

However, patient’s condition did not improve, twenty days into her hospitalization, she was

complicated with pneumonia, uncontrolled Diabetes Mellitus, liver transaminitis and lower gas-

trointestinal bleeding. Subsequently, she developed multiorgan failure and succumbed to death

due to the worsening of respiratory distress syndrome and septic shock.

Discussion

The incidence of spontaneous pneumothorax in COVID-19 patient is not yet exactly known.

Spontaneous pneumothorax is deﬁned as the presence of air in the pleural space that is not

caused by traumatic events or any precipitating factors (iatrogenic procedure or trauma), while

secondary pneumothorax is a complication of pre-existing lung disease (

). Structural changes

such as cystic and ﬁbrotic changes that occurred in the lungs parenchyma that lead to alveolar

tear were proposed to be the mechanism of spontaneous pneumothorax in COVID-19 patients

(

). Increase intrathoracic pressure due to prolonged cough and mechanical ventilation also can

precipitate spontaneous pneumothorax development (5).

Patients with COVID-19 infection can progress into acute respiratory distress syndrome (ARDS),

characterized radiographically by ground glass appearance, evolving into consolidation changes

and ﬁbrotic changes later in stage (

). Gattini et al reported the incidence of pneumothorax

is higher in patients with ARDS who are on mechanical ventilation for more than 2 weeks (

Zantah et al identiﬁed 6 out of 902 (0.66%) patients who developed spontaneous pneumothorax

in COVID-19 patients (

). Yang and colleague found that only one (1.1%) out of 92 deceased

COVID-19 patients developed pneumothorax (7).

Pneumothorax is sometimes associated with pneumomediastinum, subcutaneous emphysema

and pneumoperitoneum in COVID-19 patients. The passage of air from the thorax to the abdomen

can occur due to the presence of anatomical oriﬁces, especially in the weak areas of the diaphragm

such as the posterolateral and parasternal area (

). Spontaneous pneumomediastinum is a rare

condition that occurred when alveolar rupture, followed by air dissection through bronchovascular

sheath into the mediastinum. Subcutaneous emphysema occurred when air gets into the tissue

under the skin (

). In this case, the patient developed pneumothorax, subcutaneous emphysema

and pneumomediastinum after intubation due to respiratory distress.

Pneumoperitoneum is a surgical emergency and is usually related to perforated viscus. More

than 90% of the cases are surgical-related and the balance 10% is of nonsurgical etiology(

Perforated viscus is usually diagnosed by the presence of air under the diaphragm on erect CXR.

Laparotomy is usually considered when there is a presence of pneumoperitoneum because it is

one of the signs of perforated viscus. In our patient, CXR post-intubation revealed air under the

diaphragm, but clinically the abdomen was soft and there was no sign of peritonism. There are a

few reported cases of bowel perforation in COVID-19 patients (

)(

). Patient with COVID-19

11/13

is predispose to develop venous and arterial thromboembolic event and can lead to bowel ischemia

and perforation (

). Thorough investigation such as CT scan thorax and abdomen is necessary to

rule out non-surgical causes of spontaneous pneumoperitoneum to avoid unnecessary laparotomy

and perioperative morbidity.

Treatment for spontaneous pneumothorax in COVID-19 patients associated with pneumome-

diastinum and pneumoperitoneum remains controversial due to the lack of clinical data. Wang

et al managed their patient with a similar condition with a high ﬂow nasal cannula and steroid

therapy without chest tube insertion. The patient clinically improved with resolved pneumothorax,

subcutaneous emphysema and pneumomediastinum (

). Gemio et al treated their patient conser-

vatively due to the absence of abdominal signs. He was clinically stable and discharged home 42

days after admission (

). Munish sharma et al inserted a bilateral chest tube for their COVID-19

patient that develops non-surgical pneumoperitoneum. However, their patient succumbed to

death due to the progression of the disease. They concluded that incidental ﬁndings of pneu-

moperitoneum on X-ray or CT may not be much of signiﬁcance and such cases can be managed

conservatively (

). Sun et al reported a case of a COVID-19 patient who developed mediastinal

emphysema, giant bullae and pneumothorax which was also treated conservatively with a high

ﬂow nasal cannula and mechanical ventilation. Repeated CT scan on day 15 of conservative

treatment showed disappearance of mediastinal emphysema and improvement in the pulmonary

lesion (15).

In our case, the patient was treated conservatively by the insertion of a bilateral chest tube. Pneu-

moperitoneum on CXR resolved after chest tube insertion, however, subcutaneous emphysema

remained. Serial x-ray done showed no improvement with increasing requirement of oxygenation.

The patient ﬁnally succumbed to death due to multiorgan failure and septic shock.

Conclusion

Spontaneous pneumothorax in COVID-19 patients can lead to development of subcutaneous

emphysema, pneumomediastinum and pneumoperitoneum. The diagnostic suspicion of non-

surgical pneumoperitoneum in a COVID-19 patients is essential as it may lead to unnecessary

laparotomy. This entity required adequate clinical, radiological and clinical evaluation because

wrong diagnosis might lead to perioperative morbidity to patients and unnecessary COVID-19

exposure to operating team healthcare workers.

Conﬂict of interest

Authors declare no conﬂict of interest.

References

[1]

Coronavirus disease 2019 (COVID-19) situation report. World Health Organization;.

Accessed: 01/10/2021. Available from: https://www.who.int/emergencies/diseases/

novel-coronavirus-2019/situation-reports.Date.

[2]

Covid-19. Ministry of Health (MOH);. Accessed: 01/10/2021. https://covidnow.moh.gov.

my/.date.

[3]

Zantah M, Castillo ED, Townsend R, Dikengil F, Criner GJ. Pneumothorax in COVID-19

disease-incidence and clinical characteristics. Respiratory Research. 2020;21(1):1–9.

[4]

MacDuﬀ A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British

Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18–ii31.

[5]

Zhou C, Gao C, Xie Y, Xu M. COVID-19 with spontaneous pneumomediastinum. The Lancet

Infectious Diseases. 2020;20(4):510.

[6]

Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al.. COVID-19 pneumo-

nia: diﬀerent respiratory treatments for diﬀerent phenotypes?. Springer; 2020.

12/13

[7]

Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19.

Journal of medical virology. 2020;92(11):2511–2515.

[8]

McGlone FB, Vivion Jr CG, Meir L. Spontaneous pneumoperitoneum. Gastroenterology.

1966;51(3):393–398.

[9]

Corrêa IJF, Viana KF, Silva MBSd, Silva LMd, Oliveira Gd, Cecchini ARdS, et al. Perforated

acute abdomen in a patient with COVID-19: an atypical manifestation of the disease. Journal

of Coloproctology (Rio de Janeiro). 2020;40:269–272.

[10]

Soeselo DA, Hambali W, Theresia S. Bowel necrosis in patient with severe case of COVID-19:

a case report. BMC surgery. 2021;21(1):1–5.

[11]

De Nardi P, Parolini DC, Ripa M, Racca S, Rosati R. Bowel perforation in a Covid-19 patient:

case report. International journal of colorectal disease. 2020;35:1797–1800.

[12]

Wang W, Gao R, Zheng Y, Jiang L. COVID-19 with spontaneous pneumothorax, pneumome-

diastinum and subcutaneous emphysema. Journal of travel medicine. 2020;27(5):taaa062.

[13]

Del Rey IAG, de la Plaza Llamas R, Ramia JM, Velasco AAM, Candelas DAD. Non-surgical

spontaneous pneumoperitoneum in a COVID-19 positive patient with severe bilateral pneu-

monia. Cirugia espanola. 2020.

[14]

Sharma M, Ojha P, Taweesedt PT, Ratnani I, Surani S. An Intriguing Case of Pneumoperi-

toneum In a Patient With COVID-19: Do All Pneumoperitoneum Cases Need Surgery?

Cureus. 2020;12(12).

[15]

Sun R, Liu H, Wang X. Mediastinal emphysema, giant bulla, and pneumothorax developed

during the course of COVID-19 pneumonia. Korean Journal of Radiology. 2020;21(5):541.

13/13