Pneumatocele Formation Research Articles

Successful Management of Spontaneous Pneumatocele and Pneumothorax Formation After COVID-19 Infection

Pneumatoceles are rarely encountered in the clinical setting. Very few cases have been documented that involved COVID-19 pneumonia as a cause. Furthermore, even fewer cases document spontaneous pneumothorax complicating the pneumatocele that required urgent intervention. We present a case of a patient who developed a pneumatocele as a complication of symptomatic COVID-19 infection. The patient's clinical course was further complicated by spontaneous pneumothorax formation. The patient had thoracostomy and video-assisted thoracoscopic surgery. Here we describe the patient's clinical course in detail.

Post-COVID recurrent dyspnoea

Rationale: Post-COVID symptoms need aggressive evaluation. Patient’s Concern: A 29-year-old male patient who had suffered from COVID-19 eight weeks earlier, presented with an acute onset of breathlessness and right-sided chest pain due to pneumothorax. Emergency tube thoracostomy was performed. However, it failed to improve hypoxia. Diagnosis: High-resolution computed tomography of the thorax with computed tomography pulmonary angiography revealed pulmonary arterial thrombosis, ground-glass opacities, and bilateral pneumatoceles. Interventions: Hospital admission and treatment with low molecular weight heparin at a dose of 1.5 mg/kg every 24 h. Outcomes: The large pneumatocele showed significant resolution after three months of follow-ups. Lessons: Being increasingly reported after having a SARS-CoV-2 infection, pneumatocele formation, due to post-COVID lung scarring and late vascular thrombotic events, is a peculiar sequela and can present as acute dyspnoea. Long-term preventive anticoagulants after recovery from COVID-19 are necessary. Breathing exercises during recovery should be done with caution.

The signal transducer and activator of transcription 3 at the center of the causative gene network of the hyper-IgE syndrome.

The hyper-IgE syndrome (HIES) is characterized by atopic dermatitis with extremely high serum IgE levels and diminished inflammatory responses, in combination with bacterial and fungal infections followed by pneumatocele formation. These immunological manifestations are frequently associated with nonimmunological abnormalities, including characteristic face, pathological fracture, and retention of deciduous teeth. We previously identified that major causal variants of the HIES are dominant-negative variants in the signal transducer and activator of transcription 3 (STAT3) gene. Several new causative variants of HIES have been identified, interestingly, most of which are functionally associated with STAT3. These include a zinc finger transcription factor ZNF341 as well as IL-6 family cytokine receptors, IL6ST, and IL-6R. In this review, I will outline the pathological mechanisms of new causative variants, in which STAT3 is at the center of the causative gene network.

CASE OF ESCHERICHIA COLI NECROTIZING PNEUMONIA WITH CAVITARY LESIONS

CASE OF ESCHERICHIA COLI NECROTIZING PNEUMONIA WITH CAVITARY LESIONS

EXTENSIVE PNEUMATOCELES DUE TO PNEUMOCYSTIS JIROVECI PNEUMONIA IN A PATIENT NEWLY DIAGNOSED WITH HIV INFECTION

EXTENSIVE PNEUMATOCELES DUE TO PNEUMOCYSTIS JIROVECI PNEUMONIA IN A PATIENT NEWLY DIAGNOSED WITH HIV INFECTION

PNEUMATOCELE FORMATION FOLLOWING COVID-19 PNEUMONIA: A CASE REPORT

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Cystic lung changes are uncommon but increasingly reported complications following COVID-19 pneumonia. We report a case of COVID-19 pneumonia complicated by large pneumatocele formation. CASE PRESENTATION: A 45-year-old man with no significant medical history presented to the ED with worsening dyspnea a week after testing positive for SARS-CoV2. He was found to be hypoxemic and the chest radiograph showed bilateral opacities consistent with COVID-19 pneumonia. Patient was hospitalized and treated with supplemental oxygen, dexamethasone, remdesivir, convalescent plasma, and tocilizumab. His clinical status improved and he was discharged home after one week of hospitalization. Two weeks later, he presented again with worsening dyspnea and mild hemoptysis. Computed tomography of the chest showed large pneumatocele with focal left lower pneumothorax. Patient was hospitalized and managed conservatively as recommended by pulmonary and cardiothoracic surgery teams. He was discharged in a stable condition and was advised to seek immediate medical attention for concerning respiratory symptoms. DISCUSSION: Pneumatocele is a thin-walled cystic lung change that develops in the setting of pneumonia and is usually transient. Few cases of pneumatocele following COVID-19 pneumonia have been reported. Although it is still controversial, pneumatocele pathogenesis is potentially related to prolonged inflammation causing necrosis in the airways or alveoli with subsequent air leakage. Most of the reported cases were managed conservatively with satisfactory outcomes while the course of few other cases was complicated by development of pneumothorax requiring tube thoracostomy. CONCLUSIONS: Cystic lung changes including pneumatocele should be suspected in patients with new or worsening respiratory symptoms following recovery from COVID-19 pneumonia. DISCLOSURE: Nothing to declare. KEYWORD: COVID-19

Incidence, clinical associations and outcomes of intrathoracic complications with and without ARDS in COVID-19 pneumonia

PurposeTo determine the incidence and clinical predictors of intrathoracic complications in COVID-19 patients, and the association with outcomes. MethodsIn this retrospective cross-sectional study, we included 976 patients (age 61 ± 17 years, 62% male) who tested positive for SARS-CoV-2 between March 3–April 4, 2020 and underwent chest imaging. 3836 radiographs from 976 patients and 105 CTs from 88 patients were reviewed for intrathoracic complications, including pneumothorax, pneumomediastinum, pneumopericardium, lobar collapse, pleural effusion, and pneumatocele formation. ResultsThere was a high rate of intrathoracic complications (197/976, 20%). Pleural effusion was the most common complication (168/976, 17%). Pneumothorax (30/976, 3%) and pneumatoceles (9/88, 10%) were also frequent. History of hypertension and high initial CXR severity score were independent risk factors for complications. Patients with any intrathoracic complication during admission had an over 11-fold risk of ICU admission (adjusted odds ratio [aOR] 11.2, p < 0.0001) and intubation (aOR 12.4, p < 0.0001), over 50% reduction in successful extubation (aOR 0.49, p = 0.02) and longer length of stay (median 13 versus 5 days, p < 0.0001). There was no difference in overall survival between patients with and without any complication (log-rank p = 0.94). ConclusionIn COVID-19 patients who underwent chest imaging, 1 in 5 patients have an intrathoracic complication, which are associated with higher level of care and prolonged hospital stay. Hypertension history and high CXR severity score confer an increased risk of complication. SummaryIntrathoracic complications in COVID-19 are common and are predictive of ICU admission, need for intubation, less successful extubation, and longer length of stay but are not predictive of mortality.

Pneumatocele formation following COVID-19 pneumonia. Is there a role for surgical intervention?

COVID-19 mainly causes a lower respiratory tract illness, meaning there has been great interest in the chest and lung radiological findings seen during the course of the disease. Most of this interest has centred around the computed tomographic findings. Most commonly, computed tomographic images report ground-glass opacities but a less common finding, and potential complication associated with COVID-19, is pneumatocele formation. In this case series, we describe the presentation and management of three patients with large pneumatoceles that developed during the recovery phase of COVID-19. A conservative approach is most recommended, with surgical intervention reserved for complicated cases that cause cardiorespiratory compromise.

A pneumatocele observed in the thoracic cavity after bronchoalveolar lavage

A 76-year-old man was admitted to the respiratory medicine department with 5 days of a non-productive cough and exertional dyspnea. A computed tomography revealed multiple mild patchy consolidations in both lungs (Figure 1). Despite antibiotic therapy, there was poor improvement in laboratory and radiological parameters. A bronchoscopy was performed on day 5. The bronchoscopy was wedged in left B5 and a bronchoalveolar lavage (BAL) was performed. After the BAL, we noticed a fistula in the depth of left B5 and saw a structure like a pleural cavity in the back of the fistula (Figure 2). We diagnosed the patient’s condition as pneumatocele (PC). BAL showed 46% lymphocytes and the CD4/8 ratio as 3:7. These findings suggested cryptogenic organizing pneumonia (COP). It took 3 weeks for the PC to improve. Bilateral multiple consolidations improved after the administration of a steroid (PSL 0.5 mg/kg). PCs can occur in infections, chest trauma, barotrauma from mechanical ventilation, and bronchial interventions [1,2]. The mechanism of PC formation is closely related to that of a check valve. The check valve may be composed of exudate from inflammation and the destroyed wall of the respiratory tract [3]. In this case, it was considered that the wedged bronchoscopy and collapsed bronchial wall became the check-valve. PCs can be a severe condition including tension pneumothorax, bronchopleural fistula, and secondary infections [4]. In our case, as we were concerned about new complications due to the PC we did not prescribe a steroid for COP until the PC had improved. To our knowledge, no papers have reported internal observations of PC. We herein report the first case of PC observed in the thoracic cavity after BAL.

In-hospital clinical complications of COVID-19: a brief overview.

In-hospital clinical complications of COVID-19: a brief overview.

Spontaneous pneumothorax associated with COVID-19 pneumonia: a single-centre retrospective study.

Spontaneous pneumothorax (SP) is a rare complication of COVID-19 pneumonia; it affects both intubated and non-intubated patients. The pathogenesis includes barotrauma and pneumatocele formation. In the following article, we present case series of 18 patients with COVID-19 associated pneumothorax - a detailed demographic and clinical analysis were performed. The study revealed that men were more affected than women, especially above the age of 55 years; whilst, the distribution of intubated patients and those with spontaneous breathing were equal. Importantly, tube thoracostomy was the preferred method of treatment. The lethal outcome was observed in all patients on mechanical ventilation, due to the severe course of the underlying disease. The occurrence of pneumothorax in patients with COVID-19 is associated with poorer outcome of the disease, especially in those placed on mechanical ventilation.

Development of a Large Pneumatocele in a Patient Recovering from COVID-19 Pneumonitis.

A 39-year-old man presented with severe COVID-19 pneumonitis requiring hospital admission. He represented three days following discharge with sudden onset breathlessness and chest pain. Initial imaging suggested the presence of a left pneumothorax. Following further clinical decline a plan was made to insert a CT guided chest drain. However, imaging in the prone position for the procedure unexpectedly revealed a large left lower lobe pneumatocele with only a very small pneumothorax. Events and appearances suggest that this is a rare case of delayed COVID-19 pneumonitis-related pneumatocele formation. We will discuss the clinical significance of this entity.LEARNING POINTSPneumatocele formation should be considered in patients presenting with new respiratory symptoms after completing therapy for COVID-19 pneumonitis.Performing CT examinations with patients in different positions may be required to help exclude the possibility of pneumatocele formation when a loculated pneumothorax is suspected on the supine CT images.

Hyperimmunoglobulin E Syndrome (HIES) Treated with Thalidomide Plus Dexamethasone with Encouraging Results

Hyperimmunoglobulin E syndrome (HIES) is a rare and complex immunodeficiency disease that is characterized by recurrent skin abscesses caused by Staphylococcus aureus, recurrent pneumonia with formation of pneumatoceles, eosinophilia and serum immunoglobulin E > 2,000 IU / mL. Recent studies about the molecular changes in HIES include mutations in the gene encoding signal transducer and activator of transcription 3 (STAT3), which cause autosomal dominant form of the disease. Clinical diagnosis is established through Grimbacher criteria, because there is significant variation in the constellation of symptoms and signs among individual patients. There is no specific treatment of HIES, although therapeutic alternatives have been studied with controversial results. Several forms of treatment have been informed with bone marrow transplantation as well without benefit results. We present two cases of HiperIgE that received off - label treatment with thalidomide and dexamethasone achieving an excellent evolution, remission of symptoms and decline of IgE levels. To our knowledge this is the first report in which the disease natural history has changed with thalidomide and dexamethasone treatment with a rapid reduction of symptoms (pruritus) and IgE levels returned to normal. DisclosuresNo relevant conflicts of interest to declare.

A Case report of coronavirus disease-19-associated pulmonary aspergillosis and pneumothorax

Secondary infections in coronavirus disease (COVID)-19 pneumonia in association with lung cavitation are rare findings. The development of cavitation has been attributed to aseptic liquefaction of pulmonary thromboemboli or secondary infection, resulting in the formation of pneumatoceles. Rupture of a large pneumatocele may lead to the development of pneumothorax. We report the case of a 56-year-old male who was treated for COVID-19 pneumonia with severe acute respiratory distress syndrome (ARDS) but developed pneumothorax and a cavitary lesion in the recovery period. This was further complicated by a co-infection with Aspergillus fumigatus in endotracheal secretions. The pneumothorax failed to resolve and there was a failure to wean off mechanical ventilation, culminating in death after 2 weeks. This case report highlights the need to monitor for small pneumatoceles even in the recovery phase of COVID-19 which may predispose to pneumothorax or pneumomediastinum.

Pneumatocele formation in a fatal adult pneumonia patient coinfected with Streptococcus pyogenes emm-type 3 and influenza A: a case report

BackgroundA pneumatocele is a transient thin-walled lesion and rare complication in adult pneumonia.A variety of infectious pathogens have been reported in children with pneumatoceles. We report the first case of adult pneumonia with pneumatocele formation that is likely caused by Streptococcus pyogenes and coinfection with influenza A virus.Case presentationA 64-year-old Japanese man presented with a one-week history of fever, sore throat, and arthralgia. He was referred to our university hospital for respiratory distress. He required mechanical ventilation in the intensive care unit (ICU). Bacterial culture detected S. pyogenes in the bronchoscopic aspirates, which was not detected in blood. Although a rapid influenza antigen test was negative, an influenza A polymerase chain reaction (PCR) test was positive. Therefore, he was diagnosed with coinfection of influenza A and group A streptococcus (GAS) pneumonia complicated by probable streptococcal toxic shock syndrome. A chest radiograph on admission showed diffuse patchy opacification and consolidation in the bilateral lung fields.Multiple thin-walled cysts appeared in both middle lung fields on computed tomography (CT). On the following day, the bilateral cysts had turned into a mass-like opacity. The patient died despite intensive care. An autopsy was performed. The pathology investigation revealed multiple hematomas formed by bleeding in pneumatoceles.ConclusionsThere have been no previous reports of a pneumatocele complicated by S. pyogenes in an adult patient coinfected with influenza A. Further molecular investigation revealed that the S. pyogenes isolate had the sequence type of emm3.

Factors causing oral and skin pathological features in the hyperimmunoglobulin E syndrome patient including the environmental component: a review of the literature and own experience.

The hyperimmunoglobulin E syndrome (HIES) is a rare multi-system disease with non-immunological as well as immunological abnormalities. The syndrome is characterized by a triad of the most distinctive symptoms, such as pneumonia with pneumatocele formation, recurring staphylococcal skin abscesses and a high serum concentration of IgE. Central mediators of immune responses such as STAT1 and STAT3 affect immune responses and contribute to changes of the skin microbiome which subsequently can amplify the defective immune response against microbial and fungal pathogens. Reactions related to an environmental factor, such as sun-induced skin changes, in individuals during long-term medication therapy have also been reported. The dermatological symptoms, oral status and other health problems of a hyperimmunoglobulin E syndrome paediatric patient are presented. HIES is of great importance to different professionals because sufferers require special preventive and therapeutic management from early infancy in order to avoid complications which can even prove to be life-saving for such patients.

A rare cause of multiple Cavitatory Pneumonia

Cavitatory lesions of lung can be seen in infection, inflammation, or malignancy of lungs. Radiographic findings of thick walled cavities in the lungs are typically seen in mycobacterial infections, malignant lesions, fungal infections, pulmonary vasculitis or other inflammatory lesions of the lungs. Escherichia coli causing lung infection, especially cavitatory lesion is very rare and the few cases reported are of pneumatocele formation. Here we present an unusual case of Escherichia coli infection as a rare cause of cavitating necrotizing pneumonia, particularly causing extensive pulmonary cavities leading to destruction of the entire lung, in a 45 year old female with no co-morbidities.

Hyperimmunoglobulin E syndrome: Genetics, immunopathogenesis, clinical findings, and treatment modalities.

The hyperimmunoglobulin E syndromes (HIESs) are very rare immunodeficiency syndromes with multisystem involvement, including immune system, skeleton, connective tissue, and dentition. HIES are characterized by the classic triad of high serum levels of immunoglobulin E (IgE), recurrent staphylococcal cold skin abscess, and recurrent pneumonia with pneumatocele formation. Most cases of HIES are sporadic although can be inherited as autosomal dominant and autosomal recessive traits. A fundamental immunologic defect in HIES is not clearly elucidated but abnormal neutrophil chemotaxis due to decreased production or secretion of interferon γ has main role in the immunopathogenesis of syndrome, also distorted Th1/Th2 cytokine profile toward a Th2 bias contributes to the impaired cellular immunity and a specific pattern of infection susceptibility as well as atopic-allergic constitution of syndrome. The ophthalmic manifestations of this disorder include conjunctivitis, keratitis, spontaneous corneal perforation, recurrent giant chalazia, extensive xanthelasma, tumors of the eyelid, strabismus, and bilateral keratoconus. The diagnosis of HIES is inconclusive, dependent on the evolution of a constellation of complex multisystemic symptoms and signs which develop over the years. Until time, no treatment modality is curative for basic defect in HIES, in terms of cytokines/chemokines derangement. Of note, bone marrow transplant and a monoclonal anti-IgE (omalizumab) are hoped to be successful treatment in future.

Clinical Features, Diagnosis, and Treatment of Traumatic Pulmonary Pseudocysts

Traumatic pulmonary pseudocysts (TPP) are rare complications of blunt chest trauma. The aim of this study is to increase the understanding of this rare entity with imaging and clinical parameters for preventing complications and determining the correct treatment approach by observing 15 cases. We retrospectively reviewed the medical data and thoracic computed tomography scans of 185 patients who underwent examinations in our department after chest trauma between July 2014 and December 2015. Fifteen patients had TPPs, and their clinical features and imaging findings were evaluated. Their average age was 26.33 (range, 1-89) years. The cause of TPP was traffic accident in 13 patients and falling from a height in two. Tube thoracostomy was required in five patients. None of the patients required thoracotomy, and 66% of them recovered without any complications. Five patients died because of serious concomitant injuries. Sudden shearing force across the pulmonary parenchyma results in an area of pulmonary contusion and airtransfer from the airway to the contused area, which in turn leads to pneumatocele formation. Conservative treatment is recommended for these patients, but complications can occur because of cyst rupture. Patients should be closely monitored and be made aware of the risk of life-threatening complications.

Liver abscess in a boy with hyper IgE syndrome

Hyper immunoglobulin-E syndrome is a rare primary immunodeficiency disease, characterized by the classical triad of recurrent staphylococcal skin abscesses, pneumonia with pneumatocele formation, and elevated levels of serum IgE, usually over 2000 IU/mL. Chronic granulomatous disease, hyper IgE, and complement deficiencies are immunopathologies known to be associated with liver abscesses. We present a 2 ½-year-old boy with liver abscess and associated hyper IgE.