Case History
A 48-year-old male presented to the emergency department six days after onset of shortness of breath, cough, and chills. He tested positive for COVID-19 five days prior. On admission, vital signs showed blood pressure of 116/80 mmHg, temperature of 99.8 Fahrenheit, heart rate of 109 beats per minute, respiratory rate of 40 breaths per minute, and oxygen saturation of 72% on room air. The patient was initially placed on 6 L/min oxygen by nasal cannula and escalated to 15 L/min. Serum labs on admission were significant for sodium of 126 mg/dL (standard range 135-145), potassium of 3.4 mg/dL (standard range 3.6-5.2), C-reactive protein of 429 mg/L (standard range 0-10.0), lactate of 2.3 mMol/L (standard range 0.4-2.0), leukocytosis of 18,860 cells/L (standard range 4,000-11,000), and D-dimer of 1.52 mg/L (standard range 0-0.53). He was confirmed COVID-19 positive by reverse transcriptase-polymerase chain reaction of nasopharyngeal swab. Initial imaging revealed diffuse bilateral ground-glass infiltrates above both lung fields which was subsequently described as “tree-in-bud” acute respiratory distress syndrome. (Figure 1) Four-extremity Doppler ultrasound revealed a right upper extremity brachial vein deep vein thrombus (DVT), and the patient was placed on once daily 1 mg/kg subcutaneous enoxaparin.
On the same day as admission, the patient continued to have tachycardia, tachypnea, and low oxygen saturation despite high flow oxygen by nasal cannula and required endotracheal intubation and mechanical ventilation for the next 48 hours due to respiratory insufficiency. The patient self-extubated on day four of hospitalization and remained tachypneic until the last twelve hours of hospitalization. He was discharged on day ten and prescribed apixaban 5 mg twice daily for upper extremity DVT therapy. The patient did not require oxygen supplementation at discharge.
Three days after discharge, the patient developed a sense of fullness in his neck. Five days after discharge, his family physician made a house call and noticed that the patient had resting tachycardia at 108 beats per minute, oxygen saturation of 93% on room air, and a heart rate that increased to 140 while walking in place for one minute. The patient had faint crackles over the right posterior lung field but no evidence of subcutaneous crepitus at this time.
On the seventh day following discharge and two days after the physician house call, the patient returned to the emergency department with increasing swelling in the neck and a sensation of “crackling” in his neck, chest, and scrotum. Physical exam revealed a blood pressure of 120/70 mmHg, a heart rate of 112 beats per minute at rest, oxygen saturation of 94% on room air, a respiratory rate of 28 breaths per minute, and a temperature of 99.6 Fahrenheit. Physical exam revealed increased swelling of the neck compared to two days prior, palpable crepitus in the neck, chest, and abdomen, and diminished breath sounds over both lung bases. There was no audible Hamman’s crunch sign of a pericardial friction rub. A computed axial tomography (CT) scan revealed diffuse subcutaneous emphysema in the neck and chest with massive pneumomediastinum and marked improvement of the parenchymal infiltrates (Figure 2).
The patient was admitted to the hospital for monitoring. Forty-eight hours later, the patient’s subcutaneous emphysema spread to his arms as demonstrated by newly palpable crepitus from his axilla to the wrists. Additionally, there was significantly increased swelling and crepitus in the neck. The patient described difficulty with breathing due to a sense of local constriction in his upper airway with progressively increased stridor and increased pitch of his voice that caused great difficulty with speaking and breathing.
With concern for impending airway obstruction, the patient was taken for emergency mediastinal drainage. He received a subxiphoid pericardial window, subxiphoid and suprasternal drainage of the pneumomediastinum, substernal dissection with a lighted scope, and laryngotracheobronchoscopy. A suprasternal notch transverse incision and dissection to the anterior mediastinum was also performed. A lighted balloon tipped endoscope was used to further develop the substernal space from the subxiphoid space up to the suprasternal notch. Neither pleural space was entered. The anterior mediastinum was completely decompressed, and a Blake drain (24 French) was placed and exited through a separate space in the subxiphoid region (Figure 3). A pericardial wound was then created in this space and was drained as well with a Blake drain (24 French). Fiberoptic bronchoscopy was then conducted to confirm that there were no injuries extending down to the major bronchi. A repeat ultrasound of the upper extremity post-operatively demonstrated a complete disappearance of the brachial vein thrombus present only two weeks prior. The patient made an uneventful recovery with complete clinical and radiographic healing.