Spontaneous pneumothorax as a complication of COVID-19 infection has been described, with a majority implicating barotrauma following mechanical ventilation in an already compromised lung as a probable etiology [1,2]. The uniqueness of our case lies in its delayed presentation and recurrence, with incomplete lung expansion despite drainage, necessitating surgical intervention, and the absence of bullae or blebs on thoracoscopy. The possible mechanism of COVID-related pneumothorax is attributed to pulmonary parenchymal injury, alveolar membrane damage, and bulla formation , which when subjected to high intra-alveolar pressure during acts such as coughing or high positive end-expiratory pressure ventilation, results in pneumothorax. Our patient presented to us with pneumothorax, almost 50 days after being off positive pressure ventilation. We hypothesize that the delayed presentation of such pneumothoraces is due to the persistent chronic inflammatory changes and a delayed alveolar breach as part of an ongoing chronic disease process which is yet to be fully understood . Ruptured small subpleural blebs inciting the primary episode of pneumothorax, but later sealing off spontaneously, only to reopen later, could explain the recurrence. The multiple loculations can be ascribed to a previous inflammatory reaction secondary to COVID-related acute respiratory distress syndrome which could cause pleural adhesions creating septae within the pleural space.
Earlier reports described delayed pneumothoraces which were managed with intercostal drainage only [5,6]. From our experience, we agree with Aiolfi et al.  that early intervention through a minimally invasive approach would offer better outcomes in these patients to prevent the recurrence of pneumothorax and its associated complications. The challenges of operative management in COVID-19 patients are manifold: exposure of healthcare workers to aerosol-generating procedures (AGPs), maintenance of one-lung ventilation, the hazard of developing contralateral pneumothorax, and the dubious quality of the underlying lung tissue to withstand resection. In our case, all associated healthcare workers donned level III personnel protective equipment (PPE). We could successfully maintain one-lung ventilation probably due to the recovery of the contralateral lung following a delay in presentation. As no bulla or air leak was noted in our patient, we decided to do pleurodesis to prevent recurrent pneumothorax. Talc was not used as it is known to cause respiratory distress in some patients . Gine et al.  in a recent report expressed concerns of coagulopathy and bleeding in COVID-19 patients precluding surgical pleurodesis. No significant bleeding was noted in our case partly attributable to the late presentation.