Covid 19 Bullous Lung Disease Superinfected By Raoultella Planticola

Introduction: Bullous lung lesions from Corona Virus Disease 2019 (COVID-19) pneumonia-causing pneumothorax is a rare complication, affecting up to 1% of infected patients. Raoultella Planticola is an aerobic, gram-negative rod-shaped bacterium known to cause opportunistic infection. Only three cases of R. Planticola pneumonia reported in the United States until 2017. We present a rare case of spontaneous pneumothorax from rupture of lung bulla as a late sequela from COVID-19 pneumonia and superinfection of the bulla by R. Planticola. Case: A 37-year-old man presented to the emergency department (ED) with a sudden onset of sharp right-sided chest pain and shortness of breath after an episode of dry cough. One month before the presentation, he was tested positive for COVID-19, with the only symptom being dry cough, without hospitalization or treatment. He works in construction, never smoked. On arrival, he was in respiratory distress with tachypnea. Chest radiograph revealed subcutaneous emphysema and right-sided pneumothorax with large bleb at the right mid lung field. An emergent pigtail catheter tube was placed with the resolution of pneumothorax. Polymerase chain reaction (PCR) from nasopharyngeal swab detected infection by COVID-19. Serologic workup revealed leukocytosis and elevated erythrocyte sedimentation rate: 34 mm/hr. Computed tomography (CT) showed (Image) large right-sided bulla, bilateral patchy infiltrates. Sputum analysis was negative for bacteria, fungi, and mycobacterium tuberculosis. Further workup was negative for eosinophilia, aspergillus, autoimmune diseases, and HIV. His symptoms and leukocytosis improved without needing antibiotics or steroids. Later the chest tube was removed and was discharged. Post-discharge follow-up in the pulmonary clinic, he complained of hemoptysis and was referred to the ED. Repeat CT revealed patchy ground-glass opacities, new bullae in the left lung, and resolving right lung bulla with fluid and debris in the dependent portion, which led to suspect pneumonia and bullous infection. Sputum culture grew R. Planticola, resistant to ampicillin;he was started on amoxicillin-clavulanic acid with improvement in symptoms and was subsequently discharged. A repeat follow-up CT after a month showed resolution of bullae with scarring. Discussion: Bullous lung lesions in COVID-19 pneumonia were reported in the literature irrespective of mechanical ventilation status. Although superinfection of bullous lesions is known, this is the first reported case of R. Planticola pneumonia in a patient with COVID-19 lung bullae. COVID-19 patients are at heightened risk for bullous lung lesions and superinfection by opportunistic organisms;thus, they should be followed-up closely.