Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP, C-reactive protein.
The patient was admitted to the intensive care unit as a case of severe COVID-19 pneumonia. As per the institutional protocol at the time, he was treated with intravenous (IV) ceftriaxone, azithromycin, methylprednisolone (40 mg every 12 hourly), and IV Remdesivir. Despite treatment, the patient’s condition did not improve. The patient received multidisciplinary care throughout his admission, including physiotherapy, occupational therapy, respiratory therapy, critical care, and infectious disease. On Day 8 of ICU stay, due to persistently high oxygen requirements and increasing D-dimers (peak 8 mg/L FEU), a CT pulmonary angiogram (CTPA) was performed to rule out pulmonary embolism. The scan showed no filling defect but showed predominantly peripheral and patchy basal areas of ground-glass attenuation with multifocal segmental dense consolidation with air bronchograms, consistent with severe bilateral pneumonia due to COVID-19. In this situation O2saturation and blood pressure dropped and CT-scan of chest performed and show tension pneumopricadium (FigE,F). patient as soon as possible referred to ICU with CPAP and bilateral chest tube was insert in third intercostal space in mid clavicular line and bilateral subclavicular incision for evacuation of subcutaneous air the condition of patient improved over the next 8 days, the patient’s pneumeditiastinum moderately improved with decreased oxygen requirement(G,H,K,L). However, due to persistent shortness of breath, oxygen requirement, and persistent bubbling of chest tube, pleurodesis with autologous blood and providon iodine(6,11) the air bubbling was not stopped. The patient’s chest tube could not be removed till two months later when his pneumediastinum resolved, and he started to maintain normal oxygen saturation in room air. He was discharged after ward in an asymptomatic condition with bilateral chest rube which connected to urine bag and 45 days chest tubes was removed with no evidence of pneumeditiastinum and pneumothorax recurrence during four months following(Fig M,N,O,P) but patchy infiltration not improved.