Multiple huge bubbles forming inside the lung of a patient infected with SARS-CoV-2

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the world more than two years to come and is still affecting the world in many ways. This disease has a wide range of presentations that can range from no symptoms at all to rapid deterioration and death. Complications of SARS-CoV-2 include acute respiratory failure, pneumonia, acute respiratory distress syndrome (ARDS), acute liver injury, acute heart injury, septic shock, thromboembolism, pediatric multisystem inflammatory syndrome, and chronic fatigue. Although there are many complications like this and others, we are still seeing new developments related to the virus. In this case report, we present a patient with SARS-CoV-2 who simultaneously had a massive bleb in the left lung of unknown etiology. Given the size and size of this bubble, we suspect it is a multiple of SARS-CoV-2 infection. Few cases have been described in the literature before Here we would like to contribute one more. Our goal is to help expand the body of evidence that demonstrates the far-reaching and atypical nature that SARS-CoV-2 can provide today.

an introduction

Symptoms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily present with classic lung findings of dyspnea, changes in lung function test, pneumonia-like symptoms, and fibrotic changes [1-3]. Bubble formation is a rare symptom in relation to SARS-CoV-2.

Computer tomography (CT) of the chest plays an important role in the management of SARS-CoV-2 complications, especially in relation to pneumonia. [3]. The development of SARS-CoV-2-associated pneumonia is mainly tracked by computed tomography of the chest. When pneumonia presents with SARS-CoV-2, chest CT often initially shows ground glass opacity and consolidation. This leaves the lung with fibrocystic changes at the origin of the lung injury. However, only a few cases develop bullous pemphigoid and/or pneumothorax, as reported in the literature as of this time point. [4].

Here we present a case of a 59-year-old man, whose infection with SARS-CoV-2 was complicated by a massive pulmonary bulla.

View status

We present the case of a 59-year-old man with a previous medical history of thoracic surgery (whether lobectomy or unclear pneumonectomy) due to gunshot wound (GSW), joint pain, and cigarette smoking (40 packs per year). In October 2021, the patient experienced general weakness, abdominal pain, loss of appetite, diarrhea and dizziness for a week. He was alert, awake, oriented to place, time and person, and had shortness of breath. Physical examination revealed decreased left-sided breathing sounds. On arrival, his vitals were blood pressure 94/81 mmHg, pulse 77 bpm, temperature 36.2°C (97.2°F) (oral), respiratory rate of 16 breaths per minute, and body mass index (BMI) 25.77 kg / m². Oxygen saturation was 85% on room air and the patient was placed on a non-breathable face mask. The reverse transcriptase-polymerase chain reaction (RT-PCR) was positive for SARS-CoV-2 at the time of admission. chest radiograph (Fig 1) at the time of admission revealed the formation of multiple massive bubbles throughout the left lung, completely replacing the left lower lobe. Thoracic surgery consulted for giant pulmonary bullae.

CT scan (Fig 2) A large bubble measuring 12 x 18 x 17 cm appears in the upper halves of the chest with median pressure. There was also emphysema in the right lung. The chest surgeon did not recommend placement of a chest tube or chest surgery at the time. There were no previous relevant images to compare the current readings to.

Chest tomography: - Huge bullae inside the left lung - completely - replacement of the left upper lobe.  - multiple - additional - large bubbles - (arrows) - are - current within the left lower lobe.  Medium - severe - diffuse - air - trapped - inside - right lung - compatible - with - emphysema - with fibrotic changes.

The patient was started on a 10 L high-flow nasal cannula, dexamethasone 6 mg IV, remdesivir 100 mg IV, tocilizumab 680 mg IV, ceftriaxone 1 g, and azithromycin 500 mg IV. Because of the patient’s bleeding, no other interventions were recommended at the time of the above treatments. During the hospital course, the patient refused all treatments and blood work, despite attempts to explain to him how severe his illness was. Before treatment was completed, the patient had escaped from the hospital without medical discharge after nine days of hospitalization and had not yet been followed up or returned to the health care facility.

Discuss

This case illustrates one of the possible consequences of SARS-CoV-2. Although our patient was a smoker and had a history of thoracic surgery, the sheer size and effect of his bubbles along with his lack of prior imaging gave rise to the possibility that SARS-CoV-2 infection may have triggered the formation of bubbles. There have been other such cases describing bubbles associated with SARS-CoV-2 [5]. In the case of our patient, the SARS-CoV-2 positive case with its bubbles add another unique view to consider while searching for the complex manifestations of SARS-CoV-2.

A chest CT scan is one of the most important screening tools for SARS-CoV-2 infection. Findings include ground vitreous opacities, which are often seen in subdural regions of the lower lobe [5]. These opacities usually appear in the early stages of pneumonia and are likely to be due to changes in the alveoli – whether swelling or secretion in the alveolar space and/or septal inflammation [6].

Other lung diseases, such as influenza and acute respiratory distress syndrome, can also lead to bullous pulmonary disease [7,8]. However, there have been no reports of bullae causing a group effect reported in the literature during active infection with SARS-CoV-2. In the case of our patient, it is important not to exclude an alternative cause of his idiopathic bullae that may have appeared by chance during infection with SARS-CoV-2. But with the literature showing examples of lung damage that leads to pre-clearance of pulmonary bullae, we must include our patient’s case in the body of literature that explores the lesser known effects of SARS-CoV-2.

Unfortunately, our patient left the hospital before his treatment was completed and before additional tests and imaging were performed to explore this problem further. Our case underscores the potential for bubbles to be associated with SARS-CoV-2, and also underscores the importance of continuity of management while balancing each patient’s right to consent to tests and treatments. Bubbles are believed to be associated with basic lung diseases such as bronchitis, emphysema, cystic fibrosis, and even cancer [9]. Our patient has a history of thoracic surgery and excessive residual lung distention after lobectomy can lead to bullous changes. Our patient also had a 40-year smoking history with emphysema changes in the right lung. These could lead to bullae formation in our patient. But the development of bullae as a complication of SARS-CoV-2 infection cannot be excluded. The development/management of bullae should be monitored and managed when treating patients with SARS-CoV-2 infection.

Conclusions

As SARS-CoV-2 affects the world and burdens the healthcare system, more cases of SARS-CoV-2 are being discovered, explored, and researched. The case cited here is an example of a less common but still important case associated with SARS-CoV-2. Pulmonary bullae are rarely associated with SARS-CoV-2, making each case of bullae associated with SARS-CoV-2 essential for documentation. Pulmonary bullae associated with SARS-CoV-2 in individuals without other concomitant lung diseases may be an underdiagnosed entity. More research and case studies are needed to establish specific guidelines for treating SARS-CoV-2 secondary pulmonary bullae.

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