Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis?

Al-Azzawi, Mohammed; Douedi, Steven; Alshami, Abbas; Al-Saoudi, Ghadier; Mikhail, John

Case series Patients: Male, 36-year-old • Male, 47-year-old • Male, 78-year-old Final Diagnosis: COVID-19 • pneumomediastinum • subcutaneous emphysema Symptoms: Respiratory distress • shortness of breath Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Pulmonology OBJECTIVE: Rare co-existance of disease or pathology BACKGROUND: Novel Coronavirus 2019 (COVID-19) has been in the spotlight since the first cases were reported in December 2019. COVID-19 has been found to cause severe acute respiratory distress syndrome and, more uncommonly, subcutaneous emphysema and pneumomediastinum. We present a case series of 3 patients with COVID-19 infection managed in the Intensive Care Unit and found to have subcutaneous emphysema and pneumomediastinum on chest imaging. CASE REPORTS: We present a case series of 3 men, ages 36, 47, and 78 years, diagnosed with COVID-19 via RT-PCR, found to have severe acute respiratory distress syndrome, and managed in the Intensive Care Unit. Two patients described in this case series were mechanically ventilated on low positive end-expiratory pressures and developed subcutaneous emphysema and pneumomediastinum on chest imaging, and 1 patient developed subcutaneous emphysema prior to intubation. Each of these patients had a more eventful hospital course and worse outcomes than most COVID-19 infected patients. CONCLUSIONS: Subcutaneous emphysema and pneumomediastinum in COVID-19 patients have been rarely reported and is poorly understood. In our institution, we have found the diagnosis of subcutaneous emphysema and pneumomediastinum in COVID-19 patients is associated with unfavorable outcomes and worse prognosis.