SPONTANEOUS BILATERAL NON-RESOLVING PNEUMOTHORAX AS A COMPLICATION OF SEVERE SARS-COV-2 INFECTION

Knowledge and understanding about novel COVID-19 infection and its complications is of paramount importance in decreasing mortality on ongoing pandemic. A 40-year-old male with no past medical history arrived to the emergency clinic complaining of progressive shortness of breath and non-productive cough in the past week. He also reported worsening general malaise, headaches and fever despite recently completed antibiotic treatment with azithromycin for community acquired pneumonia. Physical examination was remarkable for tachycardia, tachypnea and bilateral respiratory crackles. Laboratory results were concerning for severe hypoxemia and lymphopenia. Bilateral pneumonic infiltrates were identified on imaging. The patient presented rapid clinical deterioration with signs of acute respiratory failure for which rapid sequence intubation protocol was followed. Inflammatory markers including ferritin levels were elevated raising suspicion for severe SARS-CoV-2, which was confirm by positive COVID-19 PCR test. After initial 48 hours with hydroxychloroquine, no clinical improvement was recorded. In view of continued clinical deterioration, the patient was enrolled in a convalescent plasma clinical trial with successful negative PCR test result after 48 hours of infusion. Results also correlated with slight clinical improvement including mechanical ventilation parameters, yet multiple attempts to wean off mechanical support were unsuccessful. Hospitalization was complicated with spontaneous bilateral pneumothorax. Multiple chest tubes were placed with minimal improvement of pneumothorax size. Exploratory bronchoscopy was performed and multiple bilateral sites of air-leak were encountered, explaining the non-resolving pneumothorax. The patient underwent exploratory thoracotomy, during which right lung fistula was corrected. Left lung pleurodesis with doxycycline was performed but unfortunately, pneumothorax persisted. Patient continued on ventilatory support for 5 months and remained with poor prognosis when this article was written. This case exposes the difficulty and complexity of caring for severe SARS-CoV-2 patients. To our knowledge there are only a handful of reported cases worldwide of COVID-19 infected patients complicated with bilateral non-resolving pneumothorax. As a novel disease, there aren't general practice guidelines to direct medical management. We describe this case in order to provide a point of reference for medical care workers treating similar patients. Many questions regarding SARS-CoV-2 infection are still unanswer, in particularly if early establishment of aggressive management would decrease incidence of this type of catastrophic lung complication.