SPONTANEOUS TENSION PNEUMOMEDIASTINUM: MANAGEMENT IN PNEUMOCYSTIS JIROVECI PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous secondary pneumothorax has been reported in up to 35% of patients with Pneumocystis jirovecii (PCJ) pneumonia with human immunodeficiency virus (HIV), however, associated with bilateral pneumothorax and pneumomediastinum is a rare life-threatening condition. We present an interesting case of non-surgical management of spontaneous bilateral pneumothorax with tension pneumomediastinum in an immunocompromised individual with mediastinal drain and large-bore chest tube at the bedside with significant improvement in symptoms and hemodynamic improvement. CASE PRESENTATION: 54 years old non-compliant with his medicines with a history of HIV, type II diabetes mellitus came with complaints of dyspnea on exertion, non-productive cough for 2-3 weeks. On admission, he was afebrile, tachypneic, tachycardiac with bilateral coarse breath sounds on physical exam. Chest x-ray on admission showed bilateral multifocal opacities without any pleural effusion or pneumothorax and initial laboratory results were unremarkable. He developed spontaneous subcutaneous emphysema with crepitus extending up to his neck and face three days into hospitalization. Computed Tomography (CT) chest showed bilateral ground-glass opacities, bilateral pneumothorax, and extensive pneumomediastinum along the neck with mass effect on the heart. Initially, bilateral chest tubes were placed with improvement in pneumothoraces but persistent air leaks. One week later, he had worsening pneumomediastinum with acute hypoxic respiratory failure and obstructive shock requiring mechanical ventilation. An emergent 8 Fr mediastinal drain was placed by the ICU team at the bedside under fluoroscopy guidance with improvement in his hemodynamic status. Bronchoscopy with bronchoalveolar lavage showed PCJ DNA on PCR. His symptoms resolved over the course of hospitalization and he was discharged home on room air after a prolonged hospitalization on Biktarvy® and trimethoprim-sulfamethoxazole. DISCUSSION: PCJ pneumonia should be considered as a cause of pulmonary infection in HIV patients, subcutaneous emphysema leading to pneumothorax and pneumomediastinum has been reported with high mortality rates. Spontaneous pneumothorax develops secondary to cyst or bleb rupture due to PCJ pneumonia. Spontaneous pneumomediastinum may occur due to an abrupt increase in the trans-alveolar pressure gradient due to infections, trauma, violent coughing, or can be iatrogenic; however, tension pneumomediastinum is extremely rare. In this case, urgent treatment of pneumomediastinum at the bedside with early treatment initiation for PCP without BAL results was a life-saving measure. CONCLUSIONS: Early recognition of symptoms in immunocompromised individuals, point-of-care ultrasound, and bedside procedures in an emergent setting in non-surgical candidates in the ICU are life-saving measures with prompt anti-microbial therapy for successful treatment. REFERENCE #1: Park YK, Jung HC, Kim SY, et al. Spontaneous Pneumomediastinum, Pneumopericardium, and Pneumothorax with Respiratory Failure in a Patient with AIDS and Pneumocystis jirovecii Pneumonia. Infect Chemother. 2014;46(3):204-208. doi:10.3947/ic.2014.46.3.204 REFERENCE #2: Yee D, Fu D, Hui C, Dharmadhikari N, Carino G. A Rare Case of 4 Ps: Bilateral Pneumothoraces and Pneumomediastinum in Pneumocystis Pneumonia. R I Med J (2013). 2020 Jun 1;103(5):52-54. PMID: 32481782 REFERENCE #3: Saleem N, Parveen S, Odigwe C, Iroegbu N. Pneumomediastinum, pneumorrhachis, and subcutaneous emphysema in Pneumocystis jiroveci pneumonia in AIDS. Proc (Bayl Univ Med Cent). 2016;29(2):188-190. doi:10.1080/08998280.2016.11929412 DISCLOSURES: No relevant relationships by Mahnoor Mir, source=Web Response No relevant relationships by Jay Peters, source=Web Response No relevant relationships by Jorge Villalpando, source=Web Response