TOPIC: Signs and Symptoms of Chest Diseases
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: Acute pulmonary manifestations of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), include dyspnea and acute respiratory distress syndrome (ARDS), have been well elucidated and represent some of its most common findings. However pneumatocele, a common pulmonary finding in a myriad of other viral and bacterial infections, has not been well documented in patients with SARS-CoV2 and may be an associated but less common pulmonary finding.
      CASE PRESENTATION: A 60-year-old non-smoking male with history of Type 1 diabetes presented as a referral to the Pulmonary clinic with symptoms of productive cough, right-sided chest and flank pain for one week. Vital signs are within normal limits. He tested positive for SARS-CoV2, Computerized Tomography (CT) Chest demonstrated multifocal bilateral ground glass opacities with small right loculated pleural effusion. At the one week follow up, his symptoms are unchanged. Repeat CT Chest demonstrated right loculated hydropneumothorax with pneumatoceles. His clinical symptoms improved after placement of a right posterior pigtail chest tube which drained 100cc of sanguineous fluid without purulence. Infectious workup were unremarkable and repeat CT Chest after 2 months demonstrated post-inflammatory scarring and thickening with resolution of pneumatocele.
      DISCUSSION: Pulmonary pneumatocele are thin-walled air-filled intrapulmonary cysts that may or may not contain air-fluid levels. These may be formed from an infectious or non-infectious etiology and are most common in the pediatric population and immunocompromised individuals. Infection-induced pneumatocele are most likely caused by the inflammatory exudates within the airway lumen and overall inflammation and narrowing of the bronchus causing air to enter but not leave resulting in the distal dilatation of the bronchi and alveoli.Pneumatocele associated with SARS-CoV2 currently described in the literature are likely to be caused by ARDS, with the hypothesis that these pneumatocele can lead to pneumothorax which is a rare complication that is now being more widely described in the literature. However, our patient was not dyspneic and did not require oxygen supplementation, so it is unlikely that he developed ARDS. Therefore, it is our hypothesis that our patient's pneumatocele was a rare complication related to his SARS-CoV2 infection.Once pneumatocele is diagnosed, it is crucial to have close follow up due to the increased risk of infection, empyema, abscess, and pneumomediastinum. Most however, can be managed conservatively as they often resolve spontaneously.
      CONCLUSIONS: It is important to keep in mind that even healthy patients with mild or asymptomatic SARS-CoV2 infections may still develop pneumatocele. Once a diagnosis of pneumatocele is established, follow up and return precautions are crucial due to the myriad of potential complications that may result.
      REFERENCE #1: 1. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). (2021, 04 06). Retrieved from Coronavirus Resource Center: Ufuk, F., & Savaş, R. (2020). Chest CT features of the novel coronavirus disease (COVID-19). Turkish journal of medical sciences, 50(4), 664–678. 3. Carotti, M., Salaffi, F., Sarzi-Puttini, P., Agostini, A., Borgheresi, A., Minorati, D., Galli, M., Marotto, D., & Giovagnoni, A. (2020). Chest CT features of coronavirus disease 2019 (COVID-19) pneumonia: key points for radiologists. La Radiologia medica, 125(7), 636–646. Pfeifer, K., Kalra, V., Adebowale, A., Juthani-Mehta, M., & Soo-Shin, M. (2014). Apical Pneumocystis jiroveci as an AIDS defining illness: A case report illustrating a change in the paradigm. Journal of radiology case reports, 8(11), 15–24. FLAHERTY, R. A., KEEGAN, J. M., & STURTEVANT, H. N. (1960). Post-pneumonic pulmonary pneumatoceles. Radiology, 74, 50–53. 6. Yang, T. C., Huang, C. H., Yu, J. W., Hsieh, F. C., & Huang, Y. F. (2010). Traumatic pneumatocele. Pediatrics and neonatology, 51(2), 135–138. 7. Brahmbhatt, N., Tamimi, O., Ellison, H., Katta, S., Youssef, J., Cortes, C., & Gotur, D. (2020). Pneumatocele and cysts in a patient with severe acute respiratory syndrome coronavirus 2 infection. JTCVS techniques, 4, 353–355. Carsana, L., Sonzogni, A., Nasr, A., Rossi, R. S., Pellegrinelli, A., Zerbi, P., Rech, R., Colombo, R., Antinori, S., Corbellino, M., Galli, M., Catena, E., Tosoni, A., Gianatti, A., & Nebuloni, M. (2020). Pulmonary post-mortem findings in a series of COVID-19 cases from northern Italy: a two-centre descriptive study. The Lancet. Infectious diseases, 20(10), 1135–1140. Ai, T., Yang, Z., Hou, H., Zhan, C., Chen, C., Lv, W., Tao, Q., Sun, Z., & Xia, L. (2020). Correlation of Chest CT and RT-PCR Testing for Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology, 296(2), E32–E40. Jamil A, Kasi A. Pneumatocele. [Updated 2020 Nov 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: 11. Sanivarapu RR, Farraj K, Sayedy N, Anjum F. Rapidly developing large pneumatocele and spontaneous pneumothorax in SARS-CoV-2 infection. Respir Med Case Rep. 2020;31:101303. doi: 10.1016/j.rmcr.2020.101303. Epub 2020 Dec 2. PMID: 33294361; PMCID: PMC7709595. 12. Batubara, E. A. D., Amanda, C., Sinambela, P., Triweda, R., & Setiawan, J. I. (2020). COVID-19 Patient Associated with Rare Pneumatocele Finding: CT Features and Case Report. Asian Journal of Case Reports in Medicine and Health, 4(1), 1-5. Retrieved from 13. Bajpai, J., Kant, S., Verma, A.K. et al. Spontaneous lung pneumatocele in an adult with community-acquired pneumonia. Egypt J Intern Med 29, 141–143 (2017).
      DISCLOSURES: No relevant relationships by Monisha Das Ireland, source=Web Response
      No relevant relationships by Kevin Wang, source=Web Response