Spontaneous mediastinal emphysema in a non-intubated patient with COVID-19 related pneumonia: a case report

Spontaneous mediastinal emphysema (ME) is a rare clinical entity often associated with sudden changes in intrathoracic pressures. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. Inflammatory alterations installed over the airway following SARS-CoV-2 infection may reduce its distensibility and compliance conferring an increased risk of developing the complication, even in the absence of mechanical ventilation. However, the exact mechanism by which ME occurs in SARS-CoV-2 pneumonia is unknown. We report a case of a 58-year-old man that presented to the emergency department with dyspnea, subcutaneous emphysema of the neck and high clinical suspicion of COVID-19 infection. There was no smoking history and no lung comorbidities. The patient was admitted into a monitored unit and received management accordingly (having never required mechanical intubation). During chest radiological evaluation ME was found and ultimately resolved with noninvasive maneuvers. We want to emphasize the importance of this adverse event despite their non-smoking history and the exclusion of positive pressure ventilation. Given the recent increase in the number of patients with COVID-19 related pneumonia, the presence of pneumomediastinum in patients with COVID-19 infection should alert the clinician to monitor the patients carefully for possible worsening of disease, especially when lung lesions are severe.