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Table of Contents
Year : 2022  |  Volume : 11  |  Issue : 5  |  Page : 38-40

Hydropneumothorax in a patient with COVID-19

1 Department of Surgery, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Radiodiagnosis, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission08-Jan-2021
Date of Decision27-Jun-2021
Date of Acceptance06-Jul-2021
Date of Web Publication07-Jul-2022

Correspondence Address:
R Ram
Medical Superintendent, Professor and Head, Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcsr.jcsr_7_21

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Pneumothorax had been reported in a few patients COVID-19. However, the significance and frequency of this association remains unclear. We report a 42-year-old man with COVID-19 disease who presented with left-sided hydropneumothorax. We managed the patient with intercostal tube drainage underwater seal, oxygen inhalation, injections remedesivir, dexamethasone, and ceftriaxone. The repeat computerised tomography scan of chest after 10 days revealed reduction in the left hydropneumothorax; no features suggestive of COVID-19 viral pneumoniawre evident.

Keywords: Hydropneumothorax, COVID-19, ground-glass opacity, crazy paving appearance

How to cite this article:
Babu P S, Krishna C M, Pradeep M, Kiran M U, Bharghav P, Kumar V K, Kumar M P, Rajesh B, Himaja S, Aishwarya P L, Lakshmi A Y, Ram R. Hydropneumothorax in a patient with COVID-19. J Clin Sci Res 2022;11, Suppl S1:38-40

How to cite this URL:
Babu P S, Krishna C M, Pradeep M, Kiran M U, Bharghav P, Kumar V K, Kumar M P, Rajesh B, Himaja S, Aishwarya P L, Lakshmi A Y, Ram R. Hydropneumothorax in a patient with COVID-19. J Clin Sci Res [serial online] 2022 [cited 2022 Oct 2];11, Suppl S1:38-40. Available from: https://www.jcsr.co.in/text.asp?2022/11/5/38/355074

  Introduction Top

According to a Fleischner Society consensus statement published on 7 April, 2020[1] computerized tomography (CT) of the lung is not indicated in patients with suspected COVID-19 and mild clinical features unless they are at risk for disease progression. CT is indicated in a patient with COVID-19 and worsening respiratory status and in a resource-constrained environment, imaging is indicated for medical triage of patients with suspected COVID-19 who present with moderate-severe clinical features and a high pretest probability of disease. CT of the chest also helps to identify and manage the pulmonary complications.

A meta-analysis, in April 2020, reported that the pooled sensitivity of CT of lung as 94% and specificity 37%[1] for the diagnosis of COVID-19. In low prevalence (<10%) countries, the positive predictive value of RT-PCR was 10-fold that of CT chest.[2]

In addition, performing CT routinely for large cohorts of patients carries additional risks[3] like the depletion of finite resources, especially personal protective equipment due to excessive usage and increased risk of viral transmission (to staff, patients and carers) as COVID-19 positive and negative patients come close in the radiology department.

  Case Report Top

We report the case of a 42-year-old male who presented with breathlessness and palpitations of a few hours duration. He had a history of dry cough and fever of 2 days' duration. He did not complain of chest pain. He had no history of trauma. He had no past history of tuberculosis. Arterial oxygen saturation measured by pulse oximetry (SpO2) was 90%. Blood pressure was 140/88 mm Hg; respirations 28/min. Nasopharyngeal swab reverse transcriptase-polymerase chain reaction (RT-PCR) test for severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) tested positive. The CT chest revealed hydropneumothorax on the left side with collapse of underlying lung and mediastinal shift to the right. It also showed multiple patchy ground glass opcification (GGO) in the right lung with subpleural predominance. The CT severity score was 7/25 [Figure 1]. The patient was started on 6 L/min oxygen inhalation by a face-mask, intravenous remdesivir, dexamethasone and ceftriaxoneas per the institute protocol. The pleural fluid analysis showed total leucocyte count 65/mm3 with 60% lymphocytes, 40% neutrophils; pleural to serum protein ratio was 0.44; pleural fluid to serum lactate dehydrogenase (LDH) ratio was 0.5; and, pleural fluid adenosine deaminase (ADA) was 6.0 U/L. Tube thoracostomy was done under local anesthesia. After 5 days of treatment, the breathlessness had reduced and the SpO2 improved to 98% without oxygen supplementation. Remdesivir, dexamethasone and ceftriaxone were administered for a total of 10 days. Repeat CT of chest after 10 days showed left hydropneumothorax with maximum thickness measuring 1.9 cm. It did not show any tracheal or mediastinal shift [Figure 2]. Repeat CT had no features that suggested atypical viral pneumonia due to COVID-19. We discharged the patient with 98% SpO2 on room air.
Figure 1: Computed tomography of the chest showing hydropneumothorax on the left side

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Figure 2: Repeat computed tomography of the chest of the same patient, done 10 days later showing left-sided hydropneumothorax with maximum thickness measuring 1.9 cm

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  Discussion Top

The primary findings on CT in adult patients with COVID-19 include GGO, crazy paving appearance (GGOs and inter-/intra-lobular septal thickening), air-space consolidation, bronchovascular thickening, traction bronchiectasis.[4],[5],[6],[7],[8] Pneumothorax has been reported in a few patients COVID-19. However, the significance and frequency of this association remain unclear. Retrospective studies[9],[10],[11] suggested that pneumothorax might occur in 1% of those requiring hospital admission, 2% in patients requiring intensive care unit admission and 1% of patients who expired due to infection. The rate of barotrauma, comprising both pneumothorax and pneumomediastinum in ventilated patients has been reported as 15%.[12]

In a multicentre retrospective study[13] from the United Kingdom, 71 patients from 16 centres were included. Of these patients 60 patients had pneumothoraces (6 also with pneumomediastinum), while 11 patients had pneumomediastinum alone. Survival at 28 days was not significantly different following pneumothorax (63.1% ± 6.5%) or isolated pneumomediastinum (53.0% ± 18.7%; P = 0.854). The incidence of pneumothorax was higher in males. The 28-day survival was not different between the sexes (males 62.5% ± 7.7% vs. females 68.4% ± 10.7%; P = 0.619). Patients above the age of 70 had a significantly lower 28-day survival than younger individuals (≥70 years 41.7% ±13.5% survival vs. <70 years 70.9% ± 6.8% survival; P = 0.018 log-rank).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

The authors are faculty members/Postgraduate students/ residents of Sri Venkateswara Institute of Medical Sciences, Tirupati, of which Journal of Clinical and Scientific Research is the official Publication. The article was subject to the journal's standard procedures, with peer review handled independently of these faculty and their research groups.

  References Top

Rubin GD, Ryerson CJ, Haramati LB, Sverzellati N, Kanne JP, Raoof S, et al. The role of chest imaging in patient management during the COVID-19 pandemic: A multinational consensus statement from the Fleischner society. Radiology 2020;296:172-80.  Back to cited text no. 1
Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, et al. Sensitivity of chest CT for COVID-19: Comparison to RT-PCR. Radiology 2020;296:E115-7.  Back to cited text no. 2
Raptis CA, Hammer MM, Short RG, Shah A, Bhalla S, Bierhals AJ, et al. Chest CT and coronavirus disease (COVID-19): A critical review of the literature to date. AJR Am J Roentgenol 2020;215:839-42.  Back to cited text no. 3
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 4
Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al. Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19). Radiology 2020;295:715-21.  Back to cited text no. 5
Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: A descriptive study. Lancet Infect Dis 2020;20:425-34.  Back to cited text no. 6
Lee EY, Ng MY, Khong PL. COVID-19 pneumonia: What has CT taught us? Lancet Infect Dis 2020;20:384-5.  Back to cited text no. 7
Zhao W, Zhong Z, Xie X, Yu Q, Liu J. Relation between chest CT findings and clinical conditions of coronavirus disease (COVID-19) pneumonia: A multicenter study. AJR Am J Roentgenol 2020;214:1072-7.  Back to cited text no. 8
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 9
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.  Back to cited text no. 10
Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020;92:2511-5.  Back to cited text no. 11
McGuinness G, Zhan C, Rosenberg N, Azour L, Wickstrom M, Mason DM, et al. Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation. Radiology 2020;297:E252-62.  Back to cited text no. 12
Martinelli AW, Ingle T, Newman J, Nadeem I, Jackson K, Lane ND, et al. COVID-19 and pneumothorax: A multicentre retrospective case series. Eur Respir J 2020;56:2002697.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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