Tracheal Diverticulum in SARS-CoV-2 Patients on Non-Invasive Ventilation A not so "Spontaneous" Cause of Pneumomediastinum? An imaging Pictorial Presentation of Two Cases with Review of Literature.

Donboklang Lynser,Pranjal Phukan,Chhunthang Daniala,Veena Mariam Joseph,Iadarilang Tiewsoh,Kaustuv Dutta

doi:10.15388/amed.2021.28.2.19

Donboklang Lynser, Pranjal Phukan + Show 4 more

Open Access

https://doi.org/10.15388/amed.2021.28.2.19

Copy DOI

Abstract

Spontaneous pneumomediastinum is a rare but potentially life-threatening condition, the incidence of which has showed an increase in patients with SARS-CoV-2 pneumonia, especially when they are on positive pressure ventilation. None of the reported cases of covid related pneumomediastinum had an associated tracheal diverticulum. Also, to the best of our knowledge, tracheal diverticulum has not been reported in patients on NIV. We report 2 cases of COVID-19 pneumonia on NIV with pneumomediastinum, which also had associated tracheal diverticulum, one of which developed after NIV. Though the establishment of causality needs further research, early detection of a tracheal diverticulum, which might be a harbinger of pneumomediastinum, can be a timely alarm to prompt titration of the pressure settings and judicious use of NIV. The role of inverted grey scale CT images in mediastinal window is a simple, yet hardly utilised radiological tool to increase detection of ‘mediastinal air’, let it be free air or air within a diverticulum. Through this case report, we would like to highlight the role of conventional and inverted CT imaging of pneumomediastinum and tracheal diverticulum in general and in SARS-CoV-2 pneumonia in particular, and to call for more objective research to throw light on the plausible relationship between pneumomediastinum and tracheal diverticulum.

Highlights

Since the beginning of the pandemic in December 2019, severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection is nothing like its predecessors, in terms of persistence, genetic evolution and diverse clinical manifestation
Ity needs further research, early detection of a tracheal diverticulum, which might be a harbinger of pneumomediastinum, can be a timely alarm to prompt titration of the pressure settings and judicious use of Non-invasive ventilation (NIV)
There has been an increase in incidence of spontaneous pneumomediastinum in patients with SARS-CoV 2 pneumonia, especially when they are on positive pressure ventilation

Summary

Introduction

Since the beginning of the pandemic in December 2019, severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection is nothing like its predecessors, in terms of persistence, genetic evolution and diverse clinical manifestation. Veena Mariam Joseph et al Tracheal Diverticulum in SARS-CoV-2 Patients on Non-Invasive Ventilation with the not often used inverted CT protocol in 2 cases of COVID-19 pneumonia on NIV with pneumomediastinum, which had associated tracheal diverticulum, one of which developed after NIV. 50-year-old man presented with fever, cough and dyspnoea for 3 days On reviewing the previously done images there was no evidence of tracheal diverticulum even on the thin cuts (1 mm) He was weaned off the NIV by gradually decreasing the pressure support and oxygen concentration, until the saturation was maintained above 94% on room air. 54-year-old man presenting with cough, breathlessness and fever for 5 days He worsened clinically and succumbed to the disease on the 15th day of admission

Findings

Discussion

Conclusion