Case 3
A 58-year-old man was diagnosed with COVID-19 pneumonia. He had a complicated past medical history, including diabetes mellitus, end-stage renal disease, status-post renal transplant, and pulmonary tuberculosis 3 years back. He had completed full course of anti-tuberculosis. He presented with worsening shortness of breath and severe pneumonia, requiring intubation on 3rd day of admission. During his stay in the ICU, he developed severe sepsis, MODS requiring antibiotics, antivirals, and steroids. He also showed signs of cytokine storm requiring IL-6 antagonist Tocilizumab. Later, he also received convalescent plasma. All the management was done according to the hospital’s COVID-19 management protocol. Prone positioning was done several times during his ICU stay. His tracheal aspirate culture grew Aspergillus ochraceus andCandida tropicalis . On day 22, the CXR showed subcutaneous emphysema with no pneumothorax but was suspicious of pneumo-mediastinum. His ventilatory settings were CMV with Fio2 40%, PEEP 10, Tidal volume 4-6 ml/kg, and a high respiratory rate. CT thorax revealed a significant amount of air within the mediastinum (tension pneumo-mediastinum). Anterior chest wall emphysema was also noted. There was no evidence of pleural effusion or pneumothorax. Bilateral diffuse ground-glass appearance and airspace opacities involving all lung lobes were seen. The pneumo-mediastinum was managed conservatively and was totally resolved without any intervention at that time. His condition deteriorated further during his stay in ICU due to severe sepsis and ARDS. Vasopressor requirements increased, and he suffered cardiac arrest on day 32. The cardiac arrest was reverted, but due to severe brain insults, his condition did not improve. He was transferred from the ICU for long-term care and rehabilitation.