Case Presentation: 41yo unvaccinated male diagnosed and treated with COVID-19 pneumonia eleven days prior represents six days after discharge for productive cough with hemoptysis. Patient was hemodynamically stable on room air with normal chemistries. CT chest demonstrated a new cavitary lesion in the left lower lobe and he empirically began antibiotics for post-viral pneumonia. When he acutely became tachycardic and hypoxic three days later, repeat imaging demonstrated bilateral pneumothoraces. Bilateral pigtail chest tubes were placed successfully. Ten days into his hospitalization, repeat imaging showed more cavitary lesions had developed. TTE, alpha-1 antitrypsin, HIV, urine streptococcus and legionella antigens, TB, fungal panel, ANA, cryptococcal antigens, and sputum cultures were all within normal limits. The overall clinical picture did not support ongoing infection and antibiotics were discontinued and chest tubes were successfully removed. Follow-up CT two weeks after discharge showed improvement in the sizes of the cavitary pulmonary nodules.

Discussion: There have been several case reports on spontaneous pneumothorax as a complication of COVID-19, though the actual predominance is unknown. Cavitary lesions are not as common a finding in patients with COVID-19 pneumonia. Formation is dependent on various host and pathogenic factors. As COVID-19 has become more prevalent, a spectrum of associated multisystem complications are being discovered with the pathophysiology being largely unknown. There have been several studies that suggest COVID-19 association with increased risk of pneumothorax and thromboembolic events, as well as association with endothelial damage to the lungs and fibrotic changes[2,3].

Conclusions: The timing of the formation of the pneumothoraces and the cavitary lesions in addition to the lack of an alternative etiology suggests COVID 19 as the cause for the patient’s pneumothoraces and cavitary lung lesions. It has been suggested that COVID-19 induced cavitation is secondary to alveolar hemorrhage and damage along with parenchymal necrosis [5]. Possible etiologies for the pneumothoraces include COVID-19 induced endothelial injury leading to necrosis and failure of structure integrity, excessive coughing due to cavitary lesions leading to alveoli rupture, or a rare case of spontaneous bilateral pneumothorax. It is important for care teams to continue to investigate new or unresolving respiratory symptoms in COVID-19 recovered patients to evaluate for these complications.

IMAGE 1: Bilateral pneumothoraces

IMAGE 2: New cavitary lesions