COVID-19 Complicated by Spontaneous Pneumothorax

Over the last few months, the coronavirus disease 2019 (COVID-19) pandemic has created overwhelming challenges for physicians across the world. While much has been described in the literature about lung infiltrates and respiratory failure associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), pneumothorax remains a relatively rare presentation with current literature indicating a rate of one percent. We describe a case series of three patients each of whom tested positive for SARS-CoV-2 on reverse-transcriptase polymerase chain reaction testing of nasopharyngeal swab specimens and presented with pneumothorax. These patients were treated at the New York City Health and Hospitals (NYC H+H) system, a network of eleven hospitals in four different boroughs of New York City. None of these patients had a history of lung disease and one patient was a previous smoker. One out of three patients died. Inflammatory markers were noted to be elevated in each of these patients to levels that have been associated with severe COVID-19 infection. CT scans in these patients showed bilateral air space disease consistent with COVID-19 pneumonia and pneumothorax with other features including pneumomediastinum, subcutaneous emphysema, and pneumatoceles. This may indicate the underlying pathogenesis of pneumothorax in these patients to involve inflammation-induced pulmonary parenchymal injury and necrosis with subsequent development of air leaks into the pleural cavity, a mechanism similar to that noted in patients during the severe acute respiratory syndrome (SARS) outbreak in 2003. Conservative management with chest tube drainage or observation was adequate for two of three patients while one patient developed multi-organ system dysfunction and eventual death.