Case 4
A 63-year-old man with a past medical history of type-2 diabetes, diabetic nephropathy presented with sudden deterioration of cognitive function, generalized fatigability, and hematuria. He was COVID-19 positive upon admission. His MRI showed infratentorial microhemorrhages. His condition deteriorated and he developed COVID-19 pneumonia and ARDS requiring intubation on day 18 of admission. He was managed with antiviral, antibiotics, as he also showed signs of cytokine storm requiring IL-6 antagonist Tocilizumab and steroids. 10 days after intubation, his CXR showed signs of pneumoperitoneum and anterior extraperitoneal air. The ventilator settings included pressure control mode with Fio2 60%, PEEP 8, pressure control 32 and respiratory rate of 28/min. His sputum culture was growing Klebsiella , Candida albicans , and Serratia marcescens .
CT scan showed evidence of mild lower neck surgical emphysema more to the right lateral side. Extensive tension pneumo-mediastinum was noted extending from the superior mediastinum, down anteriorly and posteriorly to the pre-crural and pre-cardiac space causing cardiac tension. This pneumo-mediastinum extended inferiorly to the anterior retroperitoneal space. No intraperitoneal free air was seen. Diffuse mosaic ground-glass attenuation of both lungs was noted which was consisted with ARDS.
Pneumomediastinum was managed conservatively and he recovered from this. Later he developed severe sepsis, multi-organ dysfunction and lung fibrosis and unfortunately expired one month later.