Abstract | December 19, 2022

Multiple Pneumothoraces Due to COVID-19 Related Interstitial Lung Disease in a Middle-aged Female with AIDS

Presenting Author: Olesya Balashova, BS, Medical Student, 4th year, American University of the Caribbean School of Medicine, Plantation, Florida

Coauthors: Shira Rosoph, Medical Student, 3rd year, St. George's University School of Medicine, Yaroslav Buryk, MD, Internal Medicine, Critical Care Medicine, Pulmonary Critical Care

Learning Objectives

  1. Accurately present the pertinent details of the patient’s case.
  2. Understand the limitations of chest x-ray and the importance of high-resolution CT in the diagnosis.
  3. Describe the course of management.
  4. Recognize the possible complications of COVID-19 induced pulmonary fibrosis.

Interstitial lung disease is a broad term that encompasses an extensive group of diffuse parenchymal lung diseases. They are often linked by shared features of inflammation and/or fibrosis, but the exact insult which initiates the process may be of known or unknown origin. COVID-19 has been shown to induce pulmonary fibrosis in select patients yet the major short- and long-term complications are still being widely studied. 

 

A 59-year-old female with a past medical history of hypertension, dyslipidemia, asthma, and uncontrolled HIV with a CD4 of 156 cells/m3 presented to the ED with shortness of breath. She was admitted for acute hypoxemic respiratory failure with a SpO2 of 89% on room air. She tested positive for COVID-19 and initial chest x-ray revealed hazy ill-defined perihilar/infrahilar opacities suggesting a multifocal infectious process. She was started on 2L nasal cannula, Remdesivir, Dexamethasone and broad-spectrum antibiotics. Shortly after her condition deteriorated, she was upgraded to high-flow nasal cannula (HFNC) with 100% FiO2 and a non-rebreather. She was then transferred to the ICU where her condition required extensive management.

 

Over three months, serial chest x-rays revealed an initial worsening followed by an improvement in interstitial opacity and aeration of both lung bases. However, those imaging findings did not correlate with the high amount of oxygen she required; HFNC with 70-90% FiO2 and non-rebreather. High-resolution CT was therefore indicated and provided a better representation of the underlying process which showed multifocal ground glass opacities and bilateral interstitial lung disease.

 

The patient experienced her first spontaneous pneumothorax in the right lung shortly thereafter. This was as a result of the decreased elasticity and compliance of the lung as well as the increased respiratory effort in the moments of oxygen desaturation. The first chest tube was inserted, however the lung tissue continued to harden leading down a repetitive vicious cycle of four more pneumothoraces and tube insertions with improvement and deterioration. After three months of this complex disease trajectory, the patient ultimately succumbed to the complications caused by COVID-19 related interstitial lung disease.

 

References:

  1. https://www.uptodate.com/contents/approach-to-the-adult-with-interstitial-lung-disease-clinical-evaluation
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