Spontaneous pneumothorax as unusual presenting symptom of COVID-19 pneumonia: surgical management and pathological findings

Abstract

Background: Spontaneous pneumothorax has been reported as a possibile complication of novel coronavirus associated pneumonia (COVID-19). We report two cases of COVID-19 patients who developed spontaeous and recurrent pneumothorax as a presenting symptom, treated with surgical procedure. An insight on pathological finding is given.

Case presentation: Two patients presented to our hospital with spontaneous pneumothorax associated with Sars-Cov2 infection onset. After initial conservative treatment with chest drain, both patients had a recurrence of pneumothorax during COVI-19 disease, contralateral (patient 1) or ipsilateral (patient 2) and therefore underwent lung surgery with thoracoscopy and bullectomy. Intraoperative findings of COVID-19 pneumonia were parenchymal atelectasis and vascular congestion. Lung tissue was very frail and prone to bleeding. Histological examination showed interstitial infiltration of lymphocytes and plasma cells, as seen in non specific interstitial pneumonia, together with myo-intimal thicknening of vessels with blood extravasation and microthrombi.

Conclusions: Although rarely, COVID-19 may present with spontaneous pneumothorax. Lung surgery for pneumothorax in COVID-19 patients can be safely and effectively performed when necessary.

Keywords: Bullectomy; COVID-19; Case report; Pathology; Pneumothorax; Thoracoscopy.

Fig. 1

Chest X-ray showing massive left (a) and right (b) pneumothorax in COVID-19 patient 1; preoperative CT scan showing right pneumothorax with bulla of the apical segment of the lower lobe (c) and ground glass opacities (d) typical of COVID-19 disease in patient 2

Fig. 2

Intraoperative finding of parenchymal vascular congestion and atelectasis in patient 1 (a) and in patient 2 in the site of bullectomy at the apical segment of lower lobe (b)

Fig. 3

Histological specimen. EE 400x viral cytopathic effects: nuclear pseudoinclusions (a). EE 200x vascular microthrombi associated with reduction of vascular lumen (b)