We present a case report of a middle-aged man who developed spontaneous pneumomediastinum and pneumothorax after performing spirometry. The patient was evaluated in post-COVID-19 outpatient hospital 70 days after his initial hospitalization for severe COVID-19 pneumonia. After performing forced expiratory maneuver on spirometry, high-resolution computed tomography (HRCT) showed a small right-sided pneumothorax and pneumomediastinum along the bronchi, large blood vessels, and cardiac contour with ‘ground-glass’ opacifications in all lung lobes. The patient was cardiopulmonary compensated and conservative treatment was recommended. The long-term consequences of COVID-19 pneumonia are still not suffi ciently known. Spontaneous pneumomediastinum can very rarely occur as a complication during regular investigation of lung function caused by forced expiratory maneuver on spirometry. Due to lung parenchymal damage, pneumomediastinum with or without pneumothorax in post-COVID-19 patients occurring after spirometry can be expected as a rare but possible complication.Spontani pneumomedijastinum (SPM) je rijetka komplikacija plućnih bolesti. U ovom prikazu bolesnika opisan je bolesnik koji je 70 dana nakon hospitalizacije zbog teške pneumonije COVID-19 nakon izvođenja spirometrije dobio spontani pneumomedijastinum i pneumotoraks. Na HRCT-u (CT toraksa visoke rezolucije) prsnog koša nakon spirometrije bio je vidljiv manji desnostrani pneumotoraks te pneumomedijastinum uz uzorak takozvanog \u27mliječnog stakla\u27 u svim plućnim režnjevima. Budući da je bolesnik bio kardiopulmonalno kompenziran, preporučen je konzervativni pristup i daljnje praćenje. Budući da su dugoročne posljedice pneumonije COVID-19 još uvijek nedovoljno poznate, učinci infekcije na respiracijski te druge organske sustave pratit će se u idućim godinama. SPM može nastati kao vrlo rijetka komplikacija redovnog ispitivanja plućne funkcije spirometrijom tijekom koje se provodi forsirani ekspirij. S obzirom na oštećenje plućnog parenhima uzrokovano pneumonijom COVID-19, Pneumomedijastinum se može očekivati kao moguća, iako rijetka komplikacija nakon provođenja spirometrije u razdoblju bolesti \u27post-COVID-19\u27

BEŠIĆ, DINO

LJILJA, ANJA

MARASOVIĆ, IVAN

PISKAČ ŽIVKOVIĆ, NEVENKA

RANILOVIĆ, DARJAN

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211Case ReportActa Med Croatica, 75 (2021) 211-214SPONTANEOUS PNEUMOMEDIASTINUM IN A PATIENT TWO MONTHS AFTER RECOVERY FROM COVID-19 PNEUMONIA AFTER PERFORMING SPIROMETRYANJA LJILJA1, DARJAN RANILOVIĆ1, IVAN MARASOVIĆ1, DINO BEŠIĆ2,NEVENKA PISKAČ ŽIVKOVIĆ31Dubrava University Hospital, Department of Pulmonology, Zagreb; ²Dubrava University Hospital, Department of Thoracic Surgery, Zagreb; ³Special Hospital Radiochirurgia Zagreb, Zagreb, CroatiaWe present a case report of a middle-aged man who developed spontaneous pneumomediastinum and pneumothorax after performing spirometry. The patient was evaluated in post-COVID-19 outpatient hospital 70 days after his initial hospitalization for severe COVID-19 pneumonia. After performing forced expiratory maneuver on spirometry, high-resolution computed tomography (HRCT) showed a small right-sided pneumothorax and pneumomediastinum along the bronchi, large blood vessels, and cardiac contour with ‘ground-glass’ opacifi cations in all lung lobes. The patient was cardiopulmonary compensated and conservative treatment was recommended. The long-term consequences of COVID-19 pneumonia are still not suffi ciently known. Spontaneous pneumomediastinum can very rarely occur as a complication during regular investigation of lung function caused by forced expiratory maneuver on spirometry. Due to lung parenchymal damage, pneumomediastinum with or without pneumothorax in post-COVID-19 patients occurring after spirometry can be expected as a rare but possible complication.Key words: mediastinal emphysema, COVID-19, pneumonia, pneumothorax, spirometry/adverse effectsAddress for correspondence: Dino Bešić, MD Dubrava University Hospital Avenija Gojka Šuška 6 10 000 Zagreb/Croatia E-mail: dino.zino91@gmail.comINTRODUCTIONSpontaneous pneumomediastinum (SPM), also called mediastinal emphysema, is a rare complication of lung diseases that is mostly observed in patients on me-chanical ventilation, but it can also be a consequence of cough, asthma exacerbation, or Valsalva maneuver (1). According to current literature, only a few cases of SPM in patients aft er performing spirometry have been reported (2,3). Th e real incidence of SPM is un-known because signs and symptoms on presentation are identical to acute respiratory diseases or musculo-skeletal disorders. SPM is not commonly seen in viral pneumonia, but it has been described in patients with acute COVID-19 pneumonia (1,4). SPM occurs as a consequence of air leakage aft er a small alveolar rup-ture. Other possible causes of pneumomediastinum are trauma or esophageal rupture.CASE REPORTWe present a case report of a 48-year-old male patient with a medical history of arterial hypertension. Th e fi rst symptoms of the COVID-19 disease occurred in February 2021. Th e patient had fever, dyspnea, ceph-alalgia, and myalgias, and was hospitalized on day 11 of disease in Dubrava University Hospital due to wors-ening of his respiratory symptoms. His hospital stay lasted for 11 days.During hospitalization, multi-slice computed tomog-raphy pulmonary angiography was performed for sus-picion of pulmonary embolism, which was excluded. ‘Crazy paving’ pattern and consolidations with air bronchograms were visible in all lung lobes (Figure 1), without any signs of pneumomediastinum. Th e pa-tient was treated with high fl ow oxygen therapy on a mask. He was also treated with remdesivir, glucocor-ticosteroids, low molecular weight heparin, and was discharged from the hospital in good condition. A. Ljilja, D. Ranilović, I. Marasović, D. Bešić, N. Piskač ŽivkovićSpontaneous pneumomediastinum in a patient two months aft er recovery from COVID-19 pneumonia aft er performing spirometryActa Med Croatica, 75 (2021) 211-214212Fig. 1. Bilateral pneumonia due to acute COVID-19 infection on MSCT of the thorax (blue arrows).During examination in a post-COVID-19 outpatient hospital 70 days aft er infection, the patient presented no signifi cant dyspnea or cough. His clinical exam-ination was unremarkable and he only had elevated blood pressure of 170/115 mm Hg. Aft er performing spirometry, he complained of mild pain in the thorax.Acid blood gas analysis was normal. High-resolu-tion computed tomography of the thorax, performed on the same day following spirometry, showed small right-sided pneumothorax and pneumomediastinum anterior to the trachea, along the main and lobar bron-chi on both sides, large blood vessels, and cardiac con-tour (Figures 2 and 3). Extensive ‘ground-glass’ opaci-fi cations were visible in all lung lobes in approximately 70% of pulmonary parenchyma.A thoracic surgeon was consulted and conservative treatment was recommended. Th e patient continued his follow-up in an outpatient post-COVID-19 hospi-tal. Aft er regression of pneumomediastinum, pulmo-nary rehabilitation program was recommended. Fig. 2. Coronal plane HRCT image of the thorax demonstrat-ing small right-sided pneumothorax (red arrow), pneumome-diastinum along the trachea and main bronchi (blue arrows), and extensive ‘ground-glass’ opacifi cations in all lung lobes (yellow arrows).Fig. 3. Transverse plane HRCT image of the thorax demonstrating small right-sided pneumothorax (left  arrow), pneumomediastinum anterior to the trachea (right arrow), and extensive ‘ground-glass’ opacifi cations (right arrow). DISCUSSION In this case report, we presented a patient who de-veloped spontaneous pneumomediastinum and small pneumothorax two months following recovery from COVID-19 aft er performing forced expirato-ry maneuvers on spirometry. Th e patient developed new-onset mild thoracic pain without signifi cant re-spiratory symptoms. According to a literature search on PubMed digital re-pository, no case report of spontaneous pneumomedi-astinum and pneumothorax in the months following recovery from COVID-19 aft er performing spirome-try has been described so far. In this patient, 70 days had passed from the onset of the COVID-19 symp-toms, but the patient still had signifi cant lung sequels.A case report by Denisson et al., which was published in November 2020, described a patient with pneumo-thorax and small pneumomediastinum identifi ed less than one month of the onset of COVID-19 symptoms, who had no prior lung injury either and did not re-ceive invasive ventilation. Th e authors also made a re-view of the literature of 32 case reports of spontaneous pneumothorax or pneumomediastinum in 58 patients with COVID-19 pneumonia (without a history of me-chanical ventilation or prior lung disease), of which 43 underwent chest tube placement (4). Diff use alveolar injury in severe acute COVID-19 pneumonia could be the cause of SPM, especially in patients with severe cough. In COVID-19 pneumonia, the virus causes breakdown of the alveolar membrane integrity as it infects both type I and II pneumocytes, which can be the cause of alveolar rupture (5,6).More case reports of pneumomediastinum and pneu-mothorax in acute COVID-19 pneumonia have been published (7,8). According to a current literature re-A. Ljilja, D. Ranilović, I. Marasović, D. Bešić, N. Piskač ŽivkovićSpontaneous pneumomediastinum in a patient two months aft er recovery from COVID-19 pneumonia aft er performing spirometryActa Med Croatica, 75 (2021) 211-214213view, no similar complication aft er performing spirom-etry has been described in post-COVID-19 patients so far. In our clinical practice, we had a similar case of a middle-aged female patient who developed SPM in the post-COVID-19 period (50 days aft er infection), also without prior lung disease. Th e patient had only mild dyspnea on exertion, and pneumomediastinum was not associated with spirometry in that patient (9). So far, SPM has been associated with interstitial lung diseas-es, emphysema, or asthma exacerbation. A case report by Rea et al. presents a patient with pneumomediasti-num following spirometry in combined pulmonary fi -brosis and emphysema syndrome (10). In a case report by Krasnik, a patient without underlying parenchymal lung disease developed pneumomediastinum two hours aft er performing spirometry, with symptoms of severe throat and neck pain (2). Spirometry is a safe and useful test, but physicians should be aware of the physiolog-ic changes that occur in the respiratory tract required to complete the test. Pneumomediastinum should be suspected if the patient complains of severe neck or throat pain following the procedure (2). Treatment of pneumomediastinum depends on the underlying lung conditions. Aft er an alveolar rupture, air moves into the subcutaneous tissue causing crepitus, but sometimes it can also leak into the pericardium (11) or the spine. If the patient complains of pleuritic pain, it is usually a consequence of pneumothorax. Other symptoms are dyspnea, cough, subcutaneous emphysema, dysphagia, and neck pain. Physical examination can be unremark-able in 30% of patients with SPM (12). One-third of pneumomediastinum cases cannot be detected by chest x-ray, so the symptoms can be mistakenly attributed to musculoskeletal disorders (13). Clinical examination, assessment of respiratory status, and hemodynamics are important to rule out emer-gencies such as pneumothorax, pneumopericardium, esophageal perforation, tension pneumomediastinum, etc. Tension pneumomediastinum, which is rare, can be treated with mediastinotomy (14). Th e most com-mon form of treatment is treatment of the primary disease.In conclusion, not only acute, but also post-COVID-19 patients with lung sequels are at a risk of suff ering from complications such as pneumothorax and pneu-momediastinum. Th ese complications should be sus-pected if patients complain of new-onset chest pain, dyspnea, and especially if subcutaneous emphysema and crepitus occur. Uncomplicated SPM patients are told to avoid Valsalva maneuver and physical exertion (15). If unexplained worsening of respiratory symp-toms of an unknown cause occurs in patients with post-COVID-19 lung sequels, SPM and pneumotho-rax should also be considered as a rare but possible cause.R  E  F  E  R  E  N  C  E  S1. Mohan V, Tauseen RA. Spontaneous pneumomediasti-num in COVID-19. BMJ Case Rep 2020; 13(5): e236519.2. Krasnick J. Pneumomediastinum following spirometry. Chest 2001; 120(3): 104.3. Chao CT, Yang CY. A rare complication aft er pulmonary function test: spontaneous pneumomediastinum, pneumoperi-cardium and subcutaneous emphysema. Acta Clin Belg 2013; 68(4): 306-8.4. Dennison J, Carlson S, Faehling S, Lieb M, Mubarik A. Case report: spontaneous pneumothorax in resolved, uncom-plicated COVID-19 pneumonia – a literature review. Respir Med Case Rep 2020; 31: 101291.5. Gralinski LE, Baric RS. Molecular pathology of emerging coronavirus infections. J Pathol 2015; 235(2): 185-95.6. Liu K, Zeng Y, Xie P et al. COVID-19 with cystic features on computed tomography: a case report. Medicine (Baltimore) 2020; 99(18): e20175.7. Sun R, Liu H, Wang X. Mediastinal emphysema, gi-ant bulla, and pneumothorax developed during the course of COVID-19 pneumonia. Korean J Radiol 2020; 21: 541.8. Elhakim TS, Abdul HS, Pelaez Romero C, Rodri-guez-Fuentes Y. Spontaneous pneumomediastinum, pneumo-thorax and subcutaneous emphysema in COVID-19 pneu-monia: a rare case and literature review. BMJ Case Rep 2020; 13(12): e239489.9. Ljilja A, Kovačević I, Lalić K et al. Spontaneous pneu-momediastinum in long COVID-19. Poster session presented at 52nd Annual Professional-Scientifi c Meeting of the Croatian Pulmonary Society; 2021 Oct 7-10; Rovinj, Croatia.10. Rea G, Scotto di Frega G, Fiorentino G. Pulmonary in-terstitial emphysema following spirometry in CPFE syndrome. Arch Bronconeumol 2015; 51(11): 602-3.11. Allen CJ, Teisch LF, Stahl KD. Spontaneous pneumo-mediastinum, pneumopericardium and epidural pneumatosis: insights on clinical management. Acute Card Care 2015; 17(1): 20-3.12. Sahni S, Verma S, Grullon J et al. Spontaneous pneumo-mediastinum: time for consensus. North Am J Med Sci 2013; 5(8): 460-4.13. Kaneki T, Kubo K, Kawashima A et al. Spontaneous pneumomediastinum in 33 patients: yield of chest computed tomography for the diagnosis of the mild type. Respiration 2000; 67(4): 408-11.14. Herlan DB, Landreneau RJ, Ferson PF. Massive spon-taneous subcutaneous emphysema. Acute management with infraclavicular “blow holes”. Chest 1992; 102(2): 503-5. 15. Macia I, Moya J, Ramos R et al. Spontaneous pneumo-mediastinum: 41 cases. Eur J Cardiothorac Surg 2007; 31(6): 1110-4.A. Ljilja, D. Ranilović, I. Marasović, D. Bešić, N. Piskač ŽivkovićSpontaneous pneumomediastinum in a patient two months aft er recovery from COVID-19 pneumonia aft er performing spirometryActa Med Croatica, 75 (2021) 211-214214Spontani pneumomedijastinum (SPM) je rijetka komplikacija plućnih bolesti. U ovom prikazu bolesnika opisan je bolesnik koji je 70 dana nakon hospitalizacije zbog teške pneumonije COVID-19 nakon izvođenja spirometrije dobio spontani pne-umomedijastinum i pneumotoraks. Na HRCT-u (CT toraksa visoke rezolucije) prsnog koša nakon spirometrije bio je vidljiv manji desnostrani pneumotoraks te pneumomedijastinum uz uzorak takozvanog 'mliječnog stakla' u svim plućnim režnje-vima. Budući da je bolesnik bio kardiopulmonalno kompenziran, preporučen je konzervativni pristup i daljnje praćenje. Budući da su dugoročne posljedice pneumonije COVID-19 još uvijek nedovoljno poznate, učinci infekcije na respiracijski te druge organske sustave pratit će se u idućim godinama. SPM može nastati kao vrlo rijetka komplikacija redovnog ispi-tivanja plućne funkcije spirometrijom tijekom koje se provodi forsirani ekspirij. S obzirom na oštećenje plućnog parenhima uzrokovano pneumonijom COVID-19, pneumomedijastinum se može očekivati kao moguća, iako rijetka komplikacija nakon provođenja spirometrije u razdoblju bolesti 'post-COVID-19'.Ključne riječi: medijastinalni emfi zem, COVID-19, pneumonija, pneumotoraks, spirometrija/nuspojaveS A Ž E T A KSPONTANI PNEUMOMEDIJASTINUM NAKON SPIROMETRIJE U BOLESNIKA DVA MJESECA NAKON PREBOLJENJA PNEUMONIJE COVID-19A. LJILJA1, D. RANILOVIĆ1, I. MARASOVIĆ1, D. BEŠIĆ2, N. PISKAČ ŽIVKOVIĆ31Klinička bolnica Dubrava, Zavod za pulmologiju, Zagreb; 2Klinička bolnica Dubrava, Odjel za torakalnu kirurgiju, Zagreb; 3Specijalna bolnica „Radiochirurgia Zagreb“, Zagreb, Hrvatska

SPONTANI PNEUMOMEDIJASTINUM NAKON SPIROMETRIJE U BOLESNIKA DVA MJESECA NAKON PREBOLJENJA PNEUMONIJE COVID-19

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