Case 5
A 51-year-old man with past medical history of type-2 diabetes had
worsening COVID-19 pneumonia and ARSA requiring intubation on day 10. He
developed sepsis and multi-organ dysfunction. He was managed with
antiviral, antibiotics, Tocilizumab and steroids. Two days after
intubation, his CXR showed left side subcutaneous emphysema and signs of
pneumomediastinum. His ventilator settings were CMV mode with tidal
volume 390, PEEP 8 and Fio2 of 50%. During his course in ICU, he went
into severe sepsis, MODS requiring antibiotics, antivirals, and
steroids. He also showed signs of cytokine storm requiring IL-6
antagonist Tocilizumab.
CT showed extensive pneumo-mediastinum and subcutaneous emphysema with
mild pneumo-thoraces bilaterally. The surgical emphysema extended into
the neck. The pneumo-mediastinum extended into the abdomen and appeared
anteriorly in the extraperitoneal region. Bilateral segmental branches
of the main pulmonary arteries, going towards the lower lobes, showed
filling defects.
As he also had significant pneumothorax, the right-sided chest tube was
inserted. A few hours later, he had cardiac arrest due to refractory
hypoxia requiring ECMO support. He responded to the management and was
decannulated from ECMO after 29 days. His sputum grew Enterococcus
fecalis , Klebsiella , and Serratia marcescens . He
recovered after a prolonged course in ICU and was discharged for
rehabilitation.
All five cases key lines are presented in table1.