Air Should Not be There: A Case of Pneumomediastinum and Pneumopericardium in COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus identified after widespread pneumonia cases in Wuhan, China at the end of 2019. This virus has been deemed a global pandemic and there remain many unknowns regarding the pathogenesis, management, treatment, and outcomes. This case report highlights a rare condition that possibly developed from the novel virus. A 68-year-old Hispanic male with hypertension and gastroesophageal reflux disease, presented with two weeks history of fevers, chills, cough, and progressive shortness of breath. He was found to be positive for the novel SARS-CoV-2 upon admission. He rapidly developed severe acute respiratory distress syndrome (ARDS) secondary to his coronavirus disease 2019 (COVID-19) pneumonia requiring intubation and full ventilator support associated with acute anuric renal failure requiring emergent hemodialysis catheter placement and continuous renal replacement therapy (CRRT). Two weeks after being on mechanical ventilation and CRRT, he developed episodes of hypotension and tachycardia. A chest radiograph and computed tomography (CT) scan diagnosed pneumopericardium. In the case presented, the patient's CT of his thorax demonstrated bilateral ground-glass opacities and bilateral reticulations consistent with intraparenchymal injuries, most likely from his ARDS secondary to his initial SARS-CoV-2 infection. To date, there remains an unknown association between COVID-19 and causation of pneumomediastinum and pneumopericardium. There continues to be reports of clinically significant findings of pneumomediastinum and pneumopericardium in COVID-19 patients. It is known that COVID-19 causes dysregulated inflammation leading to diffuse alveolar damage and rupture, as well as myocarditis which may he the precipitant to the development of pneumomediastinum and pneumopericardium. This case highlights the findings of pneumopericardium and pneumomediastinum in the novel SARS-CoV-2 virus. Given the multiple reported cases with similar time frames to the development of spontaneous pneumomediastinum in COVID-19 patients, an association between COVID-19 and spontaneous pneumomediaslinum should be further studied.