Recurrent Hydropneumothorax After COVID-19

Abstract

A 60-year-old male with a past medical history of heart failure with reduced ejection fraction, obstructive sleep apnea, atrial flutter, and hypertension initially presented to the emergency department with a chief complaint of shortness of breath. He was diagnosed with COVID-19-induced acute hypoxic respiratory failure. Before his presentation to the emergency department, he was treated with a brief course of hydroxychloroquine, azithromycin, and prednisone. His initial hospitalization was relatively uncomplicated. He then presented back to the emergency department approximately five months later with chief complaints of continued dyspnea and increased work of breathing. On this presentation, he was noted to have a right-sided pneumothorax with a moderate right-sided pleural effusion. The effusion was drained through CT (computed tomography)-guided catheter insertion. Pleural fluid culture and sensitivity were negative, and a cartridge-based nucleic acid amplification test (CBNAAT) was not performed. He was discharged a few days later to home. Over the next several weeks, the patient had recurrent admissions and chest tube placements for unresolving hydropneumothorax. He eventually had a right-sided posterolateral thoracotomy performed. The tissue sample from the thoracotomy was noted to have positive gram staining for fungal hyphae consistent with aspergillosis. This was initially considered a contaminant and not treated with antifungal medication. Unfortunately, after the thoracotomy, the patient continued to have complications including subcutaneous emphysema and recurring hydropneumothoraces. He was taken for another procedure after a repeat CT showed intercostal herniation of the pleura between the fifth and sixth ribs. The herniation was excised, and the pleura was repaired. This pleural tissue was then sent to pathology and noted to have non-caseating granulomas consistent with aspergillosis. At this time, the patient was started on voriconazole. After initiating this medication, the patient's last chest x-ray showed stable findings of his chronic disease process with no new or worsening hydropneumothorax.

Keywords: covid-19; exploratory thoracotomy; pleuropulmonary aspergillosis; recurrent hydropneumothorax; voriconazole.

Figure 1. Computed tomography angiogram (CTA) chest

The blue arrow shows that 40-50% right-sided pneumothorax has developed without obvious leftward cardio mediastinal shift. The red arrow shows moderate-sized layering right pleural effusion.

Figure 2. Computed tomography (CT) chest with contrast

The red arrow shows a large right-sided hydropneumothorax comprising approximately 50% of the right hemithorax volume. The yellow arrow shows the development of pneumomediastinum.

Figure 3. Computed tomography angiogram (CTA) chest

The red arrows show the right hydropneumothorax. The blue arrow shows intercostal herniation of the pleura between the right fifth and sixth ribs out into the right lateral chest wall.

Figure 4. Surgical pathology

Evidence of noncaseating granulomas on surgical pathology.

Figure 5. Gram stain

Positive Gram stain showing fungal hyphae with septae and predominately 45-degree angle branching consistent with aspergillosis.

Figure 6. Postoperative chest X-ray at the outpatient clinic

Chronic-appearing postoperative pleural parenchymal scarring laterally in the right hemithorax from the recent surgery. There is a trace residual volume of pleural fluid in the right lung base.