A Case Report of Spontaneous Pneumothorax in the 2019 Novel Coronavirus–Infected Pneumonia

Background: COVID-19,which pathogen virus o�cially named SARS-CoV-2, started in China Wuhan city and so far rapidly spread to a global outbreak. Since the lung is the main lesion organ for virus invasion, Chest CT is strongly recommended in COVID-19 on either initial diagnosis and follow-up.Multiple patchy shadows and ground glass opacity of bilateral lung are typical features of CT scan,and spontaneous pneumothorax appeared in the early onset of COVID-19 is rare. Case Presentation: We reported one case of spontaneous pneumothorax in the early onset of COVID-19, chest CT showed only a small amount of pneumothorax were seen in the right lobe.After receiving 4 days of treatment, re-examination chest CT shows right pneumothorax disappeared, but the patient was clinically worse, and progressive multiple diffuse consolidation. Although treatment with extracorporeal membrane oxygenator,the patient died 15 days after admission. Conclusion: Spontaneous pneumothorax in the early stages of COVID-19 is rare,which imaging features differ from other lung diseases complicated with pneumothorax,such as COPD.More than we usually know,the improvement of pneumothorax and the outcome of COVID-19 may be inconsistent.


Introduction
COVID-19,which pathogen virus o cially named SARS-CoV-2, started in China Wuhan city and so far rapidly spread to a global outbreak (1,2).Since the lung is the main lesion organ for virus invasion, multiple patchy shadows and ground glass opacity of bilateral lung are typical features of CT scan (3) ,and pneumothorax appeared in the early onset of COVID-19 is rare.Here we report a fatal case of COVID-19 with spontaneous pneumothorax.

Case Presentation
A 67-year-old woman presented to the hospital with a 15-day history of low-grade fever,fatigue,cough and progressive dyspnea.She had never smoked and denied any chronic underlying illness.At admission, physical examination revealed a body temperature of 37.6°C (99.68°F), respiratory rate of 26 breaths per minute, pulse of 92 beats per minute, and 66% oxygen saturation in ambient air.Lung auscultation revealed coarse breath sounds of both lungs .Laboratory studies showed white blood cell count 9.0 × 10 9 /L.The white blood cell differential count showed 82.9% neutrophils and 11.1% lymphocyte.There were elevated blood levels for C-reactive protein (24.07 mg/L; normal range, 0-4 mg/L), and D-dimer (7890 ng/mL; normal range, 0-500 ng/mL).Chest CT showed multiple diffuse consolidation and groundglass opacities in bilateral lungs.A small amount of pneumothorax were seen in the right lobe (Figure , A

Discussion
China and the rest of the world are experiencing an outbreak of a novel coronavirus known as SARS-CoV-2 that caused a public health emergency of international concern (4).The most appropriate treatment regimens for COVID-19 still have not been rmly established despite several new agents that are currently under investigation.Since the lung is the main lesion organ for virus invasion,chest CT is strongly recommended in COVID-19 on either initial diagnosis and follow-up.Most common features of CT scan is bilateral ground glass opcity in the disease,atypical imaging features including pleural effusion, lymphadenopathy and bronchial wall thickening 5 ,and spontaneous pneumothorax was rare,as pneumothorax is well-known complications of mechanical ventilation when support treatment for COVID-19.
We reported one case of spontaneous pneumothorax in the early onset of COVID-19,the virus damage to the alveoli and persistent cough in COVID-19 can be the causative factor for spontaneous pneumothorax in this patient.Though spontaneous pneumothorax occurs in the initial diease is seldom seen. it has a signi cant impact on treatment and prognosis, and early identi cation of pneumothorax is critical.When pneumothorax accompanied by respiratory failure,correcting hypoxia can be tricky.In view of exercising noninvasive or invasive ventilator can aggravate pneumothorax, ECMO may be the appropriate therapy .Calamitously,if the disease is critical, the chances of survival are slim.Our case suggests that lung tissue compression may not be severe in the presence of pneumothorax in COVID-19 compared with other diseases,such as COPD.and the improvement of pneumothorax and the outcome of COVID-19 may be inconsistent.

Conclusion
Spontaneous pneumothorax in the early stages of COVID-19 is rare,which imaging features differ from other lung diseases complicated with pneumothorax,such as COPD.More than we usually know,the improvement of pneumothorax and the outcome of COVID-19 may be inconsistent.When COVID-19 complicated with pneumothorax, it can have an impact on treatment, especially occurs with respiratory failure,which correlates with poor outcome of COVID-19.
).A nucleic acid ampli cation test was positive for severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 by nasopharyngeal swab.The diagnosis of severe 2019 novel coronavirus-infected pneumonia (COVID-19) was made.After receiving 4 days of treatment, the patient was clinically worse, reexamination chest CT shows right pneumothorax disappeared,but progressive multiple diffuse consolidation(Figure, B).Although treatment with extracorporeal membrane oxygenator ECMO ,the patient died 15 days after admission.