Bilateral Spontaneous Pneumothorax Research Articles

A RARE CASE OF BILATERAL SPONTANEOUS TENSION PNEUMOTHORAX IN A PATIENT WITH MUCORMYCOSIS

Mucormycosis is an invasive fungal infection seen in immunocompromised hosts. Here a rare case of mucormycosis with pulmonary involvement followed by bilateral spontaneous tension pneumothorax is described. Bilateral spontaneous tension pneumothorax is a rare and fatal condition. We present a case of 3 years old child, diagnosed case of acute Leukemia. During the course of induction chemotherapy, he was hospitalized with fever and diarrhea. He was being managed on lines of neutropenic colitis. During the hospital stay, the child developed sudden respiratory distress and seizures. Chest X-ray showed bilateral spontaneous tension pneumothorax. Immediate bilateral chest tubes insertions were done. He was also electively intubated. After successful lung expansion, the trial of weaning off the ventilator was given and patient was successfully extubated. CT Thorax after lung re-expansion showed few pneumatoceles with no bronchopleural fistulous communication. CT Brain and para nasal sinuses showed fungal rhinosinusitis with intracranial extension. Nasal endoscopy and debridement of necrotic tissue was done. Tissue cultures showed the growth of mucor species. The patient was also started on amphotericin B that was later changed to Posaconazole. He responded well to anti-fungal treatment and there was no recurrence of pneumothorax. Keywords: Mucormycosis, Tension pneumothorax, Bronchopulmonary fistula

Deoxyguanosine kinase deficiency and recurrent spontaneous pneumothorax: a case report

BackgroundDeoxyguanosine kinase deficiency is mainly manifested by hepatic and neurological damage, hence it belongs to the hepatocerebral form of mitochondrial deoxyribonucleic acid depletion syndrome. The association between deoxyguanosine kinase deficiency and recurrent spontaneous pneumothorax has not currently been reported.Case presentationA 12-year-old Russian boy with deoxyguanosine kinase deficiency, a recipient of a liver transplant with amyotrophy secondary to his mitochondriopathy, presented with recurrent spontaneous bilateral pneumothorax refractory to drainage and surgery.ConclusionTo our knowledge, this is the first documented case of deoxyguanosine kinase deficiency associated with recurrent spontaneous pneumothorax, which could be considered a late complication of deoxyguanosine kinase deficiency. At this point, this is only an association and further studies and research need to be performed to help confirm the pathogenesis of this association.

Bilateral Changes in the Lungs of a Pregnant Woman Caused by Bilateral Spontaneous Pneumothorax

Abstract Lymphangioleiomyomatosis (LAM) is a rare disease that most commonly affects women of reproductive age. The disease is manifested by diffuse destruction of the pulmonary parenchyma with the formation of cysts on a characteristic finding of multidetector computerized tomography (MD-CT) of the chest. It is thought that the presence of cells with estrogen and progesterone receptors among proliferating smooth muscle cells lead to the spread of cystic structures lined by endothelial cells. Towards the end of pregnancy and after childbirth, collapse of the lung parenchyma or rupture of the cyst wall occurs causing a dramatic clinical picture in the form of pneumothorax. Sirolimus is the only drug of choice that should improve and stabilize the patient’s pulmonary function and quality of life. Unfortunately, this drug is not always effective enough, so only option for treatment is bilateral lung transplantation. The authors present the patient in the last trimester of pregnancy who was admitted to the hospital with clinical picture of bilateral spontaneous pneumothorax. Dramatic picture of pneumothorax could not be solved solely by drainage in which atypical segmental resection of the lung was performed within a few days so on these samples lymphangioleiomyomatosis were diagnosed.

Spontaneous bilateral pneumothorax in a previously healthy COVID-19 patient: A case report

Coronavirus disease 2019 (COVID-19) is commonly linked with mild cough, fever, and shortness of breath symptoms. However, there have been reports of pneumothorax, which particularly occurred at least 1 week following symptom onset in elderly COVID-19 patients. Spontaneous pneumothorax (SP) is an uncommon but possibly fatal complication of COVID-19 pneumonia and is rarely reported in non-intubated patients. We report a case of a healthy, non-smoker 35-year-old young woman who presented with a 7-day cough, fever, and sudden shortness of breath. She was diagnosed with severe COVID-19 pneumonia, experienced a right SP, and developed a second pneumothorax on the contralateral side. She improved gradually following chest tube insertion in the right lung and conservative management for the left pneumothorax.

Bilateral spontaneous pneumothorax as a late complication of COVID‐19, a clinical case report

Bilateral spontaneous pneumothorax and sudden dyspnea can occur as late complication in patients with COVID-19 even without any history of mechanical ventilation usage. Bilateral spontaneous pneumothorax can occur as a late complication in patients with COVID-19, even without any history of mechanical ventilation. Here, we present a patient with mild COVID-19 pneumonia with a left massive pneumothorax in the third week of hospitalization and the addition of a right pneumothorax.

Lung Metastases of Soft Tissue Sarcoma Revealed by Bilateral Spontaneous Pneumothorax

Spontaneous pneumothorax is a relatively rare complication of metastatic lung tumors. In most of the previously reported cases, pulmonary metastases associated with spontaneous pneumothorax tended to originate from osteosarcoma or soft-tissue sarcomas. We hereby report a case of a bilateral spontaneous pneumothorax, in a 45 years-old female revealing lung metastasis of a soft tissue sarcoma.

Spontaneous Bilateral Pneumothorax in a Healthy Young Adult: A Comprehensive Case Report

Spontaneous Bilateral Pneumothorax in a Healthy Young Adult: A Comprehensive Case Report

Bilateral Spontaneous Pneumothorax in a Child with Multisystem Inflammatory Syndrome Associated with COVID-19

Introduction: Spontaneous pneumothorax is a rare complication of coronavirus disease 2019 (COVID-19), primarily reported in adults. Pediatric cases with bilateral pneumothorax are much less reported. Case Presentation: We presented the case of a five-year-old previously healthy boy who developed persistent fever, abdominal pain, generalized maculopapular rash, and dyspnea before admission. His chest computed tomography (CT) showed a viral involvement pattern of pneumonia suggestive of COVID-19. Subsequently, he was confirmed with multisystem inflammatory syndrome in children (MIS-C). While he responded well to the therapies, on the fifth day of admission, he developed respiratory distress again. A chest roentgenogram showed bilateral spontaneous pneumothorax. Bilateral chest tubes were inserted, and his condition improved significantly after five days of admission to the intensive care unit. Two weeks later, he was discharged in good condition. Conclusions: Children with MIS-C associated with COVID-19 may develop primary spontaneous pneumothorax. Owing to the clinical picture overlapping with MIS-C associated with COVID-19, the timely diagnosis of pneumothorax may be challenging in such patients.

BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

Spontaneous bilateral pneumothorax and pneumomediastinum independent of mechanical ventilation as complications of COVID-19 pneumonia: A case report.

Since the beginning of the COVID-19 pandemic, several infected patients have suffered from unusual and severe complications. Among these rare complications, pneumothorax and pneumomediastinum have attracted clinical attention. Such complications might be challenging to diagnose immediately because of the atypical presentation in some cases. Accurate diagnosis is essential to ensure effective treatment. Here, we present the case of a 62-year-old male who presented with symptoms of COVID-19 acute respiratory distress. There was diffuse subcutaneous emphysema in the face, neck, shoulder, and chest wall on clinical examination. The patient was started on oxygenation via a non-rebreather mask. On further evaluation, his chest X-ray revealed bilateral peripheral opacities in the lung fields, bilateral pneumothorax, and subcutaneous emphysema, after which intercostal drainage tubes were inserted. The patient's oxygen saturation was not satisfactory, and he was switched to a high-flow nasal cannula. However, his condition deteriorated, and he was put on mechanical ventilation and inotropic support. Despite our best efforts, the patient succumbed to the disease. We want to emphasize the importance of this adverse event despite his nonsmoking history and the exclusion of positive pressure ventilation. Although benign, early diagnosis of this condition is vital, as the condition could lead to worse morbidity if left unrecognized.

Iatrogenic Pneumopericardium in a Male Full-Term Newborn with Spontaneous Pneumothorax

Abstract Neonatal pneumopericardium, a collection of air in the pericardial sac, is less common form of air leak syndrome, but unfortunately with high mortality rate. We report a rare case of male fullterm newborn who soon after birth presented with respiratory distress. Chest radiograph showed spontaneous bilateral pneumothorax after which a chest drain was placed between anterior and midaxillary line in the 5th right intercostal space. The infant soon presented with tachypnea, dyspnea, muffled heart sounds, acidosis indicating cardiorespiratory worsening. On chest radiograph ‘’Halo” sign appeared indicating pneumopericardium. We believe that spontaneous reposition of a chest drain damaged the pericardial sac which combined with ventilation mechanism (‘’Macklin effect”) most likely led to pneumopericardium. After partial chest drain extraction the infant showed signs of improvement, but had to be closely monitored due to risk of tension pneumopericardium. Careful thoracal drain placement and fixation is crucial to prevent iatrogenic pneumopericardium, which can lead to deadly tension pneumopericardium.

A rare complication of COVID-19 infection: bilateral spontaneous pneumothorax and pneumomediastinum

Coronavirus 2019 (COVID-19) infection has affected the whole world since the end of 2019. Patients with the disease may present with various symptoms and develop various associated complications. Spontaneous bilateral pneumothorax and pneumomediastinum can also be detected in patients with COVID-19 who do not receive positive pressure ventilation support and do present with an intense cough. A case of bilateral spontaneous pneumothorax and pneumomediastinum over the course of the COVID-19 infection in a young male patient is reported.

Simultaneous Bilateral Primary Spontaneous Pneumothorax (SBPSP) in a young male athlete: A rare presentation

Simultaneous Bilateral Primary Spontaneous Pneumothorax (SBPSP) in a young male athlete: A rare presentation

Bilateral spontaneous pneumothorax in a non-intubated COVID-19 patient

Spontaneous bilateral pneumothorax is a rare condition occurring only in 1,3% of cases of spontaneous pneumothorax. Although spontaneous pneumothorax is recognized complication of COVID it is usually associated with severe cases of COVID pneumonia with massive lung involvement and a high level of inflammatory cytokines – so called "inflammatory storm". Large percentage of this patients requires life support with mechanical ventilation and pneumothorax is usually accompanied with pneumomediastinum. Nevertheless occurrence of spontaneous pneumothorax in non-intubated patients is very low. Therefore the presented case is exceptional in two ways – spontaneous pneumothorax occurred in non-intubated patient and is presented bilaterally. Early diagnosis of spontaneous bilateral pneumothorax can pose a diagnostic dilemma as it mimics progression of lung involvement in the course of COVID, pulmonary embolism or myocardial infarction. In our case apart from COVID pneumonia, patient had typical clinical presentation of myocardial infarction and known coronary artery disease, which initially mislead clinicians toward diagnosis of myocardial infarction (MI). However after exclusion of MI, chest radiograph was requested which revealed bilateral pneumothorax. The exact mechanism of pneumothorax development in non-intubated patients is not clear. Lung inflammation in COVID causes formation of pneumatocele, which can predispose to spontaneous pneumothorax. It is important to note that our patient developed pneumothorax without evident pneumatocele, underlying lung condition or history of trauma. This case shows that bilateral pneumothorax in COVID-19 can develop also in patients with only mild clinical course of COVID pneumonia. Early diagnosis and proper management is essential and can prevent life-threatening complications.

P12‐38: A young woman with bilateral primary spontaneous pneumothorax

P12‐38: A young woman with bilateral primary spontaneous pneumothorax

SPILLED MILK: BUFFALO CHEST WITH BILATERAL CHYLOTHORAX

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The term "buffalo chest" is used to define a single pleural space with no anatomic separation of the two hemithoraces, seen in an American buffalo or bison. There have been less than ten cases reported where spontaneous bilateral pneumothorax was suspected due to interpleural communication. The interpleural connection reported have been associated with major invasive thoracic procedures such as esophagectomy, cardiothoracic surgery, pacemaker and central venous catheter placements. We present a rare case of simultaneous bilateral chylothorax fashioned by such an interpleural communication. CASE PRESENTATION: A 45-year-old male chronic smoker with past medical history of esophagitis presented with one week of cough and reflux. He otherwise denied fevers, odynophagia, chest pain, weight loss or early satiety. He was hypoxic on admission requiring 2 L oxygen supplementation. Physical exam revealed decreased breath sounds in the left lower lung base. Chest radiograph showed minimal atelectasis at the left lung base. CT Chest showed a large sliding hiatal hernia with distention of esophagus and centrilobular nodules in the right middle lobe and bilateral lower lobes. The presumptive diagnosis was aspiration pneumonia likely secondary to hiatal hernia. Thus, he underwent laparoscopic para-esophageal hernia repair with EGD. Two days later, he developed acute hypoxic respiratory failure and was intubated. Chest radiograph was concerning for new large bilateral pleural effusions. Within hours, he underwent an ultrasound guided right thoracentesis draining four liters of opaque, pink, non-purulent fluid (figure 1). Left thoracentesis drained only five mL. Pleural fluid revealed pH 7.48, elevated triglycerides (600 mg/dL) and low cholesterol (50 mg/dL) indicating chylothorax. He had bilateral chest tubes placed and was on placed on bowel rest. Decision was made to evaluate for thoracic duct injury in the setting of recent hiatal hernia repair and he was taken for right video-assisted thoracoscopic surgery with thoracic duct ligation and talc pleurodesis. It was seen that there was a communication from the pleural cavity into the mediastinal area from the hiatal hernia dissection. This interpleural communication explained the resolution of the bilateral chylothorax with a single right-sided thoracentesis. Patient was extubated thereafter and was discharged. DISCUSSION: This report documents a rare case of bilateral chylothorax completely resolved with a single sided thoracentesis. The phenomenon was explained by the interpleural connection formed during hiatal hernia repair suggesting buffalo chest. CONCLUSIONS: Recognition of buffalo chest syndrome as a life-threatening complication is important in the setting of iatrogenic injuries during mediastinal surgeries. Prompt resolution can be achieved with a single sided thoracentesis. REFERENCE #1: Eguchi T, Hamanaka K, Kobayashi N, et al. Occurrence of a simultaneous bilateral spontaneous pneumothorax due to a pleuro-pleural communication. Ann Thorac Surg 2011;92:1124-6 Hartin DJ, Kendall R, Boyle AA, et al. Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleuropleural communication. Emerg Med J 2006;23:483-6 REFERENCE #2: Männer J, Jakob C, Steding G, et al. Horseshoe lung: report on a new variant—"inverted" horseshoe lung--with embryological reflections on the formal pathogenesis of horseshoe lungs. Ann Anat 2001;183:261-5 REFERENCE #3: Rali AS, Manyam H. Bilateral Pneumothoraces Following BiV ICD Placement: A Case of Buffalo Chest Syndrome. Am J Case Rep. 2015;16:703–6. DISCLOSURES: No relevant relationships by Jaclyn Boozalis, source=Web Response No relevant relationships by Kevin Ferriter, source=Web Response No relevant relationships by Paul Harford, source=Web Response No relevant relationships by Kanza Muzaffar, source=Web Response No relevant relationships by Nisha Soneji, source=Admin input

RARE CASE OF PAZOPANIB-ASSOCIATED BILATERAL PNEUMOTHORACES IN A PATIENT WITH METASTATIC SYNOVIAL SARCOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bilateral pneumothoraces are a rare occurrence, comprising 1.4% to 7.6% of cases [1]. Secondary causes of pneumothorax include bullous emphysema, cystic parenchymal lung disease and tuberculous lung disease [2]. Malignancy is a rare cause of pneumothorax, yet sarcomas have been associated with pneumothorax in 2% of patients [3]. Pazopanib, a tyrosine kinase inhibitor used in the treatment of metastasized sarcoma, has been shown to have a 3.3% risk of developing pneumothorax [4]. CASE PRESENTATION: A 24-year-old previously healthy Yemeni female initially presented with left-sided groin pain and swelling. Computed tomography of the pelvis showed a large heterogeneous mass in the proximal left thigh. Biopsy was consistent with synovial sarcoma. Staging via chest computed tomography showed multiple pulmonary nodules concerning for metastasis. Over the course of two years, she failed multiple lines of chemotherapy and had progression of disease with new and enlarging bilateral pulmonary nodules. She was started on fourth-line chemotherapy with pazopanib (Votrient) 400 mg daily. Two months later, she presented with shortness of breath, found to be tachypneic, tachycardic and hypoxemic. Chest x-ray revealed bilateral pneumothoraces with left mediastinal shift concerning for tension pneumothorax. Two tube thoracostomies were placed; however, course was complicated by persistent air leak bilaterally, requiring video-assisted thoracoscopic surgery with bullectomy and surgical talc pleurodesis. Patient had a slow resolution of pneumothorax and subsequently discharged home without recurrence. DISCUSSION: Bilateral pneumothoraces can be life-threatening and are associated with poor long term prognosis, especially in patients with poor underlying lung function [5]. Pneumothorax is seen in approximately 2% of sarcoma patients with pulmonary metastases. In patients with sarcoma and pulmonary metastases, 41.6% of pneumothoraces were bilateral, and typically associated with multiple lung nodules, cystic or cavitary lesions, or presence of pleural nodules or thickening [3]. Additionally, cytotoxic agents have been shown to induce cavitation in pulmonary lesions and increase the risk of pneumothorax development [6]. Per the PALETTE trial which led to the approval of pazopanib for use in sarcoma, there was a 3.3% risk for pneumothorax development [4], comparable to the baseline rate of pneumothorax development in patients with sarcoma. Nevertheless, bilateral pneumothoraces carry potentially fatal consequences. CONCLUSIONS: In patients with sarcoma undergoing treatment with pazopanib, a bilateral pneumothorax, though rare, may be life threatening and should be acutely suspected. REFERENCE #1: TG Rim, JS Bae, YS Yuk. Life-Threatening Simulatenous Bilateral Spontaneous Tension Pneumothorax - A case report. Korean J Thorac Cardiovasc Surg. 2011 Jun; 44(3): 253-256.2. Mason RJ, Braoddus VC, Murray JF, Nadel JA. Murray and Nadel's Textbook of Respiratory Medicine. 4th ed. Elsevier Saunders (2005); Vol 2, Chapter 81. Philadelphia, PA. REFERENCE #2: Hoag JB, Sherman M, Fasihuddin Q, Lund ME. A comprehensive review of spontaneous pneumothorax complicating sarcoma. CHEST. 2010 Sep; 138(3);510-8.4. Van der Graaf WT, Blay JY, Chawla SP, Kim DW, et al. Pazopanib for metastatic soft-tissue sarcoma (PALETTE): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2012 May 19; 379(9829):1879-86. REFERENCE #3: Graf-Deuel E, Knoblauch, A. Simultaneous bilateral spontaneous pneumothorax. CHEST. 1994 Apr; 105(4):1142-6.6. Interiano RB, McCarville MB, Wu J, Davidoff AM, Sandoval J, Navid F. Pneumothorax as a complication of combination antiangiogenic therapy in children and young adults with refractory/recurrent solid tumors. J Pediatr Surg. 2015 Sep; 50(9):1484-9. DISCLOSURES: No relevant relationships by Sally Askar, source=Web Response No relevant relationships by Owais Nadeem, source=Web Response

PLEURAL FLUID IN A PNEUMOTHORAX: DON'T ANCHOR IN SHALLOW WATER

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: During the 1980's Pneumocystis pneumonia (PCP) was the leading cause of HIV-AIDS related death. The diagnostic standard is by PCR. While pneumocystis is now an incorporated differential in HIV-AIDS patients with respiratory failure, sputum or bronchoalveolar lavage, samples can be difficult to obtain in non-intubated patients. We present a patient being presumptively treated for COVID in the midst of the pandemic, with spontaneous bilateral pneumothoraces and newly diagnosed HIV, for whom analysis of scant pleural fluid led to key diagnostic and treatment implications. CASE PRESENTATION: A 36-year-old, male with no medical history was admitted to an outside hospital for progressive hypoxemic respiratory failure requiring high-flow nasal cannula, secondary to presumptive COVID-19 pneumonia despite several negative PCR and antibody tests. He developed a secondary spontaneous pneumothorax on hospital day 10, for which a pigtail catheter was placed, and he subsequently was transferred to our institution for severe ARDS treatment. Prior to transfer, he received Tocilizumab, dexamethasone, and convalescent plasma per institutional COVID-19 guidelines. Due to persistently low WBC counts and failure to respond to therapy, an HIV test on hospital day 10 resulted positive, as well as a CD-4 count <50 cells/mm3. Due to the new diagnosis of HIV-AIDS, Pneumocystis pneumonia was suspected, and treatment was initiated despite pending diagnostic confirmation. On arrival, existing pigtail chest tube showed intermittent leak with enlarging pneumothorax thus a second tube was placed. After insertion, pleural fluid was sent for cell-count and microbiologic studies resulting in positive PCP. Treatment continued with Trimethoprim-Sulfamethoxazole. The patient ultimately developed bilateral pneumothoraces, required intubation, and subsequent ECMO. DISCUSSION: This case highlights two pertinent clinical points: the under-appreciated diagnostic utility of pleural-fluid sampling, and the importance of recognizing anchoring bias.While PCP is typically diagnosed from sputum or BAL samples, pleural fluid sampling has only been done anecdotally in the context of known PCP infections after prior treatment with Pentamidine. The positive PCP result on pleural fluid analysis confirmed the diagnosis despite the patient being unable to produce sputum and too unstable for BAL. While treatment was initiated empirically, the importance of diagnostic confirmation cannot be understated in a patient being subjected to immunosuppressive therapy and a worsening clinical course. Therefore, the under-appreciated and under-utilized analysis of the scant pleural fluid obtained after pneumothorax decompression, as well as the consequences of anchoring bias are exemplified in this case. CONCLUSIONS: Pneumothrax is a common complication of PCP, and minimal pleural fluid expelled after decompression is an important diagnostic source. REFERENCE #1: Thomas CF, Limper AH. Pneumocystis Pneumonia. N Engl J Med. 2004;350: 2487–2498. doi:10.1056/NEJMra032588 REFERENCE #2: Schaumberg TH, Schnapp LM, Taylor KG, Golden JA. Diagnosis of pneumocystis carinii infection in HIV-seropositive patients by identification of P carinii in pleural fluid. Chest. 1993;103: 1890–1891. REFERENCE #3: Horowitz ML, Schiff M, Samuels J, Russo R, Schnader J. Pneumocystis carinii Pleural Effusion: Pathogenesis and Pleural Fluid Analysis. Am Rev Respir Dis. 1993;148: 232–234. DISCLOSURES: No relevant relationships by Saad Ahmad, source=Web Response No relevant relationships by Alfredo Astua, source=Web Response No relevant relationships by Richard Durrance, source=Web Response No relevant relationships by Jonathan Vincent Reyes, source=Web Response

PARAQUAT INDUCED BILATERAL SPONTANEOUS PNEUMOTHORAX-DAISLEY BARTON SYNDROME – A CASE REPORT

Paraquat (1,1-dimethyl-4, 4-bipyridylium dichloride) is an effective herbicide which is widely used all over the world and India is no exception. It is toxic to humans due to its redox activity which produces superoxide anions. Accidental or suicidal poisoning causes ulceration over the mouth and gastrointestinal tract and the majority of patients die of acute renal failure, hepatic failure and acute lung injury causing mainly lung brosis and consolidation. Treatment of paraquat poisoning is extremely difcult as it does not have any specic antidote. Treatment is mainly symptomatic. Very few patients may develop spontaneous pneumothorax, known as Daisley Barton syndrome, which further impairs survival of the patient Here we present a patient of paraquat induced spontaneous bilateral pneumothorax who survived with conservative treatment.

SPONTANEOUS TENSION PNEUMOMEDIASTINUM: MANAGEMENT IN PNEUMOCYSTIS JIROVECI PNEUMONIA

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