Rare COVID-19 pneumonia complication makes patient management ‘extremely challenging,’ radiologists warn

Imaging researchers from the U.K. are warning of a rare complication from COVID-19 pneumonia that can potentially make patient management “extremely challenging.”

Carlo Urigo, MD, and colleagues illustrated their concerns with the case of one 54-year-old male patient who recently presented to a National Health Services emergency room. He had no history of smoking, asthma or underlying lung disease. But chest x-rays and CT scans revealed severe bilateral COVID-19 pneumonia, complicated by pneumomediastinum—the abnormal presence of air or gas in the center of the chest, he wrote Saturday.

Given the high degree of involvement in both lungs and “extreme” oxygen deprivation, the patient eventually fell into cardio-respiratory arrest and died just two hours after showing up at the ED.

“The role of the CT in the diagnosis of the COVID-19 infection is controversial however in our institution we found it to be beneficial if used along with the clinical presentation, when there was a delay in the result of the reverse-transcriptase polymerase-chain reaction,” Urigo and colleagues in imaging at Ealing Hospital in London, wrote Oct. 2 in Radiology Case Reports. “It is crucial then to accurately assess the severity of the parenchymal involvement. The role of CT in this scenario is particularly relevant to aid prognostication,” they added later.

Only a few previous studies have reported this connection between coronaviruses and spontaneous pneumomediastinum, tying this complication to the SARS outbreak in 2002. Typically, it is more likely to occur in those at an advanced stage of the disease when it begins causing damage and breakdown of the alveolar membrane’s integrity, leading to infection.

In the 54-year-old man’s case, he had experienced nonproductive coughing for 10 days, along with deteriorating shortness of breath for the last four. While he had no past instances of COPD or substance abuse, the individual did have a known history of hypertension and Type 2 diabetes.

A chest CT scan showed gas locules adjacent to the anterior aspect of the right heart border, along with extensive ground glass opacification throughout the lungs. Providers put out a cardiac arrest call and decided against intubation, since chances of survival were “extremely poor.” They also did not attempt cardiopulmonary resuscitation prior to his death.  

“In conclusion, spontaneous pneumomediastinum is a rare complication of COVID-19 pneumonia. It has been previously described in patients affected by SARS and may be related to widespread alveolar damage caused by the lung infection. A pneumomediastinum with severe parenchymal pneumonia, makes the management of a patient extremely challenging,” the team wrote. “Careful review of this area on chest radiograph is suggested,” they added later.

Read more about this concern in Radiology Case Reports here.