Case History
A 48-year-old male presented to the emergency department six days after
onset of shortness of breath, cough, and chills. He tested positive for
COVID-19 five days prior. On admission, vital signs showed blood
pressure of 116/80 mmHg, temperature of 99.8 Fahrenheit, heart rate of
109 beats per minute, respiratory rate of 40 breaths per minute, and
oxygen saturation of 72% on room air. The patient was initially placed
on 6 L/min oxygen by nasal cannula and escalated to 15 L/min. Serum labs
on admission were significant for sodium of 126 mg/dL (standard range
135-145), potassium of 3.4 mg/dL (standard range 3.6-5.2), C-reactive
protein of 429 mg/L (standard range 0-10.0), lactate of 2.3 mMol/L
(standard range 0.4-2.0), leukocytosis of 18,860 cells/L (standard range
4,000-11,000), and D-dimer of 1.52 mg/L (standard range 0-0.53). He was
confirmed COVID-19 positive by reverse transcriptase-polymerase chain
reaction of nasopharyngeal swab. Initial imaging revealed diffuse
bilateral ground-glass infiltrates above both lung fields which was
subsequently described as “tree-in-bud” acute respiratory distress
syndrome. (Figure 1) Four-extremity Doppler ultrasound revealed a right
upper extremity brachial vein deep vein thrombus (DVT), and the patient
was placed on once daily 1 mg/kg subcutaneous enoxaparin.
On the same day as admission, the patient continued to have tachycardia,
tachypnea, and low oxygen saturation despite high flow oxygen by nasal
cannula and required endotracheal intubation and mechanical ventilation
for the next 48 hours due to respiratory insufficiency. The patient
self-extubated on day four of hospitalization and remained tachypneic
until the last twelve hours of hospitalization. He was discharged on day
ten and prescribed apixaban 5 mg twice daily for upper extremity DVT
therapy. The patient did not require oxygen supplementation at
discharge.
Three days after discharge, the patient developed a sense of fullness in
his neck. Five days after discharge, his family physician made a house
call and noticed that the patient had resting tachycardia at 108 beats
per minute, oxygen saturation of 93% on room air, and a heart rate that
increased to 140 while walking in place for one minute. The patient had
faint crackles over the right posterior lung field but no evidence of
subcutaneous crepitus at this time.
On the seventh day following discharge and two days after the physician
house call, the patient returned to the emergency department with
increasing swelling in the neck and a sensation of “crackling” in his
neck, chest, and scrotum. Physical exam revealed a blood pressure of
120/70 mmHg, a heart rate of 112 beats per minute at rest, oxygen
saturation of 94% on room air, a respiratory rate of 28 breaths per
minute, and a temperature of 99.6 Fahrenheit. Physical exam revealed
increased swelling of the neck compared to two days prior, palpable
crepitus in the neck, chest, and abdomen, and diminished breath sounds
over both lung bases. There was no audible Hamman’s crunch sign of a
pericardial friction rub. A computed axial tomography (CT) scan revealed
diffuse subcutaneous emphysema in the neck and chest with massive
pneumomediastinum and marked improvement of the parenchymal infiltrates
(Figure 2).
The patient was admitted to the hospital for monitoring. Forty-eight
hours later, the patient’s subcutaneous emphysema spread to his arms as
demonstrated by newly palpable crepitus from his axilla to the wrists.
Additionally, there was significantly increased swelling and crepitus in
the neck. The patient described difficulty with breathing due to a sense
of local constriction in his upper airway with progressively increased
stridor and increased pitch of his voice that caused great difficulty
with speaking and breathing.
With concern for impending airway obstruction, the patient was taken for
emergency mediastinal drainage. He received a subxiphoid pericardial
window, subxiphoid and suprasternal drainage of the pneumomediastinum,
substernal dissection with a lighted scope, and
laryngotracheobronchoscopy. A suprasternal notch transverse incision and
dissection to the anterior mediastinum was also performed. A lighted
balloon tipped endoscope was used to further develop the substernal
space from the subxiphoid space up to the suprasternal notch. Neither
pleural space was entered. The anterior mediastinum was completely
decompressed, and a Blake drain (24 French) was placed and exited
through a separate space in the subxiphoid region (Figure 3). A
pericardial wound was then created in this space and was drained as well
with a Blake drain (24 French). Fiberoptic bronchoscopy was then
conducted to confirm that there were no injuries extending down to the
major bronchi. A repeat ultrasound of the upper extremity
post-operatively demonstrated a complete disappearance of the brachial
vein thrombus present only two weeks prior. The patient made an
uneventful recovery with complete clinical and radiographic healing.