Pneumatocele formation following COVID-19 pneumonia. Is there a role for surgical intervention?

Abstract

COVID-19 mainly causes a lower respiratory tract illness, meaning there has been great interest in the chest and lung radiological findings seen during the course of the disease. Most of this interest has centred around the computed tomographic findings. Most commonly, computed tomographic images report ground-glass opacities but a less common finding, and potential complication associated with COVID-19, is pneumatocele formation. In this case series, we describe the presentation and management of three patients with large pneumatoceles that developed during the recovery phase of COVID-19. A conservative approach is most recommended, with surgical intervention reserved for complicated cases that cause cardiorespiratory compromise.

Keywords: COVID-19; Pneumatocele; pneumothorax; thorax.

Figure 1.

Chest X-ray on admission with bilateral diffuse infiltrations centred in the right middle zone. The image quality is affected due to under penetration and slight rotation of the radiograph.

Figure 2.

Initial computed tomographic (CT) scan with a finding of air cavity, suggestive of left-sided, moderate in size loculated pneumothorax or potential bulla formation (blue arrow). A small cyst in the right upper lobe was also noted (green arrow).

Figure 3.

The left-sided air cavity, gradually increasing in size and filling with fluid (blue arrow). The right-sided cyst has also enlarged (green arrow).

Figure 4.

Computed tomographic (CT) scan following attempts at CT-guided drain insertion, showing the persistence of the left-sided air cavity (blue arrow) with an obvious iatrogenic pneumothorax (yellow arrow). The right-sided air cavity continues to grow in size (green arrow).

Figure 5.

Chest X-ray showing the large left-sided pneumatocele, partially filled with fluid (blue arrow) (a). Follow-up chest X-ray showing the same left-sided pneumatocele being empty from fluid (blue arrow), following an episode of productive cough (b).

Figure 6.

Computed tomographic (CT) scan on re-admission with right chest pain. The left-sided pneumatocele is still obvious but decreased in size (blue arrow). The right-sided pneumatocele has started to fill with fluid (green arrow) and there is an obvious pleural effusion (yellow arrow).

Figure 7.

Five-month follow-up chest X-ray after initial presentation. Small residual pneumatoceles in both lungs without any fluid in their cavities (blue arrows outline visible left lung findings).

Figure 8.

Chest X-ray on admission with bilateral diffuse infiltrations.

Figure 9.

Chest X-ray (CXR) in the recovery phase showed the left-sided pneumatocele (a), which persisted in a 3-month follow-up chest X-ray (b) and computed tomographic (CT) scan (c) (represented with a blue arrow in all images). Only one pneumatocele was demonstrated in these images.

Figure 10.

Chest X-ray on admission with patchy consolidation throughout the right lung and less in the left lung base.

Figure 11.

Chest X-ray scan on re-admission showed the left-sided pneumothorax with mediastinal shift to right (blue arrow) and right-sided pneumatoceles (green arrow) (a). Resolved pneumothorax left, but right pneumatocele persists (green arrow) (b).

Figure 12.

Computed tomographic (CT) scan confirming the existence of right (green arrow) and left (blue arrow) pneumatocele formation at the same time with pulmonary embolism (not obvious in this image).

Figure 13.

Three-month follow-up CT scan. Decrease in right (green arrow) and left (blue arrow) pneumatoceles, which have been completely replaced by fluid.