Introduction: COVID-19 pneumonia can cause a wide range of complications including pneumothorax, empyema, and in severe cases it can lead to bronchopleural fistula formation (BPF). Spontaneous pneumothorax is associated with worse outcomes in patients with COVID-19. It can occur with or without a pre-existing lung disease, mechanical ventilation, or external event. BPF formation is a serious complication of COVID-19 presenting as an abnormal communication between the pleural space and any of the main branches of the bronchial tree. A diagnosis of BPF is associated with a high morbidity rate if left untreated. 

Case Presentation: A 77-year-old male with a history of hypertension, presented to the emergency department for evaluation of flu and COVID like symptoms including rhinorrhea, anosmia, anorexia, headaches, and generalized weakness. The patient had been feeling weak and was unable to ambulate. On admission initial troponins were elevated to 0.46, requiring a heparin drip, and chest x-ray demonstrated patchy interstitial opacification and ground glass throughout the lungs without a pleural effusion, pneumothorax, and normal cardiomediastinal silhouette. Shortly after the patient developed a pneumothorax and had a pigtail catheter placed. After chest tube placement the patient was noted to have a persistent air leak ultimately requiring surgical fixation. 

Final Diagnosis: In an elderly patient positive for SARS-CoV-2, in the setting of a spontaneous pneumothorax with a persistent air leak following chest tube placement a diagnosis of a BPF was made. When it was noted that there was no improvement with conservative measures, surgical options were considered. Video-Assisted Thoracic Surgery (VATS) with Talc Pleurodesis and chest tube placement were required. Following surgery, the patient had resolution of his pneumothorax however continued to display a persistent air leak. By post operative day 15 the air leak had resolved, and his chest tube was removed. 

Management/Outcome: VATS is a safe and effective option for surgical management in an elderly patient with a persistent air leak even in the setting of COVID-19. Additionally, earlier treatment should be considered to reduce patient’s hospitalization. In this unique case, a SARS-CoV-2 positive, elderly patient significantly improved postoperatively with minimal complications and was safely discharged home.

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