Spontaneous Pneumothorax in an Elderly Patient With Coronavirus Disease (COVID-19) Pneumonia

DISCUSSION

Spontaneous pneumothorax can be subdivided into primary or secondary. Primary spontaneous pneumothorax (PSP) occurs in patients without known lung disease. Secondary spontaneous pneumothorax (SSP) occurrences are attributed to an underlying lung disease. SSP usually occurs in older patients and can often be linked to genetic causes.³ Many factors can increase the risk for spontaneous pneumothorax such as age, smoking, and sex. A study done in the United Kingdom reported that spontaneous pneumothorax appeared to present in a bimodal distribution (age 15 to 34 years and age >55 years). This distribution appeared to correlate with PSP being more common in the younger age group (15 to 34 years) and SSP being more common in the older age group (>55 years).⁴

Although COVID-19 data are still being collected, other viral pneumonias have been associated with pneumothorax. In a study published in 2000, 1.2% of patients with pneumonia attributed to human immunodeficiency virus (HIV) were found to have pneumothorax.⁵ The patients with HIV pneumonias were commonly diagnosed with other superimposed infections.

Spontaneous pneumothorax associated with COVID-19 in nonintubated patients was not a commonly reported complication in June 2020. One case documented in South Korea involved a young, otherwise healthy male whose severe cough was thought to be a potential cause for the pneumothorax.¹ Another case involved a 50-year-old male who developed a pneumothorax as a late sequela of COVID-19.⁶ The patient reportedly was recovering from his infection at home with supplemental oxygen when the pneumothorax occurred.

Pneumothoraces in patients with COVID-19 were documented in 2 published reports from Wuhan, China; pneumothorax was identified in 1 of 92 COVID-19–positive patients and 1 of 99 COVID-19–positive patients, respectively.^7,8 A systematic review of CT imaging of 919 COVID-19–positive patients described pneumothorax as an uncommon complication but one that was observed with disease progression.⁹

Our patient was not intubated at any point during her hospitalization, and she did not require additional noninvasive breathing assistance beyond the nonrebreather mask. She did not have a severe cough, hemoptysis, or significant tobacco use history. She denied any known medical history of lung or respiratory problems. The patient was diagnosed with SSP because of her viral pneumonia. Her viral pneumonia symptoms were relatively mild at presentation, so chest CT was not ordered on arrival. She did not exhibit significant cough or respiratory distress, and her hypoxia was initially attributed to pneumonia and heart failure. CT studies can be helpful in providing detailed information regarding lung structure and disease progression as described in South Korean and Chinese reports.^1,10 When considering other viral pneumonias as reported by Afessa, the superimposed bacterial infection could have potentially increased the patient's risk for pneumothorax.⁵ Our patient empirically completed a course of treatment for community-acquired pneumonia with ceftriaxone and azithromycin.

As the patient's oxygen requirements increased, her clinical picture did not appear to be consistent with pneumo-thorax. Rather, her symptoms were initially attributed to the progression of her viral pneumonia.