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CASE REPORT Table of Contents  
Ahead of print publication
A case of post Covid-19 pulmonary cysts and pneumatoceles


1 Department of Medicine, MVJ Medical College and Research Centre, Bengaluru, Karnataka, India
2 Department of General Medicine, MVJ Medical College, RGUHS Affiliated, Bengaluru, Karnataka, India

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Date of Submission15-Sep-2021
Date of Decision02-Nov-2021
Date of Acceptance20-Nov-2021
Date of Web Publication30-Sep-2022
 

  Abstract 


With time, newer pulmonary and extrapulmonary manifestations of postacute coronavirus disease (COVID) syndrome are being reported. This is a case report of a 67-year-old diabetic and hypertensive female who presented with persistent progressive cough and breathlessness 2 months after she was diagnosed and treated for COVID-19. The patient was admitted and worked up as a case of postacute COVID syndrome. She was radiologically detected to have diffuse, large, multiple cystic air-filled cavitary lesions all over the lungs bilaterally. Despite adequate treatment and support with oxygen supplementation, the patient's condition kept on worsening, and she was thus referred to a higher center for cardiothoracic vascular surgical intervention.

Keywords: Postacute COVID-19, pulmonary cyst, pulmonary pneumatocele


How to cite this URL:
Rehman TB, Kamath V, Vinay R B, Vardarajulu R. A case of post Covid-19 pulmonary cysts and pneumatoceles. APIK J Int Med [Epub ahead of print] [cited 2022 Dec 4]. Available from: https://www.ajim.in/preprintarticle.asp?id=357509





  Introduction Top


Coronavirus disease 2019 (COVID-19) has spared no organ system, is well known, and evidence proven. As we balance between managing the known complications of COVID-19 and discovering the unknown, the antigenic drifts continue to distract us and challenge our abilities. Usually, the pulmonary lesions in clinically cured cases of viral pneumonia gradually resolve and show complete remission. In very few severe patients, there are residual lesions and fibrosis. Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new disease, the healing process of infected pulmonary lesions is not well known and is variable. Hereby, we are presenting a case of multilocular pulmonary cysts in a case of COVID-19.


  Case Report Top


A 67-year-old, retired schoolteacher presented with dry cough for 2 months and breathlessness that progressed from Grade 1 to grade 4 modified Medical Research Council: grading System for Breathlessness in a span of 2 months. She was tested reverse transcription-polymerase chain reaction (RT-PCR) positive for COVID-19, 2 months back, and treated as per moderate case protocol according to the Ministry of Health and Family Welfare guidelines[1] in a government COVID facility and in view of persistent symptoms was shifted to our hospital and received treatment as for severe case. The patient was a known case of diabetes mellitus and systemic hypertension for 6 years on irregular medications. Patients' vital parameters were quite stable except that she required 6 L of oxygen supplementation and maintained a saturation of 85% at room air initially. Routine laboratory investigations showed anemia with a hemoglobin of 9g%, thrombocytopenia (65,000cells/cumm), hypokalemia (2.8meq/dl), hypoalbuminemia (albumin-1.91g/dl) and raised inflammatory markers (D-dimer: 902ng/ml initially, repeated 3 days later to be 1536ng/ml, serum ferritin: 238ng/ml, Lactate dehydrogenase: 597μ/l, C-reactive protein: 49mg/l). Renal and Liver function tests were otherwise unremarkable.

Electrocardiogram showed sinus tachycardia and 2D Echocardiogram showed Concentric left ventricular hypertrophy, Ejection fraction -55% and pulmonary arterial systolic pressure of 28 mm Hg.

While radiological investigations - chest radiogram showed 4 large cystic cavities, three in the right lung and one in the left upper lobe [Figure 1].
Figure 1: Chest radiogram showing multiple cavities bilaterally

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High-resolution computed tomography of the chest showed multiple, large, variably sized thick and irregularly walled cavitary lesions in the right upper and middle lobes, and left upper lobe of the lung parenchyma. These cavities contained air-fluid levels, thick irregular walls, and irregular fibrotic and atelectatic bands between them, some of these cavities were surrounded by areas of consolidation [Figure 2].
Figure 2: HRCT images in coronal(A), sagittal(B) and axial(C) sections showing multiple irregularly walled cysts with air fluid

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Arterial gas analysis showed PH-7.4; PCO2-40 mmHg; PO2-95.3 mmHg; HCO3-30.9 mmol/L; BE-8.6 mmol/l initially and a subsequent arterial blood gas analysis showed PH-7.32; PCO2-71.6 mmHg; PO2-60 mmHg; HCO3-37.3 mmol/l; BE-11.2 mmol/l. inferred to have worsening respiratory acidosis with hypercapnic or type 2 respiratory failure.

Sputum Gram stain revealed normal flora and had no acid-fast bacilli, sputum cartridge-based nucleic acid amplification test (CBNAAT) also did not detect any tubercular nucleic acid. The patient was planned for a bronchoalveolar lavage sampling for CBNAAT.

Outcome and follow-up

The patient was referred to a cardiothoracic vascular surgery center for aspiration of contents of the cavity or a transthoracic lung biopsy to test for fungal infections such as Mucormycosis and Aspergillosis as bronchoalveolar lavage was not feasible while oxygen dependency requiring 10 l/min.


  Discussion Top


SARS-CoV-2 causing COVID-19 induces lung injury of varying severity, potentially causing severe acute respiratory distress syndrome (ARDS). Pulmonary injury patterns in COVID-19 patients differ from those in patients with other causes of ARDS. Besides lung injury, a prothrombotic state has emerged as an important characteristic of COVID-19. Data from both clinical studies and postmortem case series demonstrate a high incidence of thromboembolic events.[2],[3],[4],[5] These events include pulmonary artery occlusions, which may have a thrombotic or thromboembolic origin.[6] Cavitations reflect lung infarcts undergoing liquefaction, secondary to thrombotic pulmonary artery branch occlusions. Lung cavitations appear to be a frequent complication of severely ill COVID-19 patients, probably related to the prothrombotic state associated with COVID-19.

A similar case study of 51-year-old COVID-19 pneumonia[7] was found to have cavities 3 weeks later after the initial infection, whereas in our case, most of the lung parenchyma was replaced by four large cavities by 6 weeks.

Many case reports of bacterial coinfections in COVID-19 causing pulmonary cysts[8],[9] have been described. One such in an 86-year-old in the context of COVID-19 with necrotizing pneumonia caused by Enterococcus faecalis has been described,[10] unlike in our case where there was no such coinfections.

A retrospective study by Kruse et al.[11] in 39 critically ill adult patients hospitalized with SARS CoV2 including lung injury of varying severity in Berlin/Germany found lung cavitations in an unusually large proportion that is 22 out of 39 (56%) COVID-19 patients treated in intensive care units (ICU), which also included 3 of 5 patients that did not require mechanical ventilation. Patients who developed cavitations were older and had a higher body mass index (BMI). Similarly, our patient was aged 65 years and had a higher BMI was a severe case requiring ICU care.

Gurumurthy et al.[12] studied computed tomography (CT) findings in 298 confirmed cases of COVID-19 pneumonia with positive RT-PCR the most common presenting symptoms were fever (n = 197 [66.1%]) and cough (n = 139 [46.6%]). Of 298 cases of COVID-19 pneumonia, 218 cases (73.1%) showed typical CT features, whereas 63 cases (21.1%) showed atypical CT features with concurrent classical findings, and the remaining 17 cases (5.8%) were normal. Among the atypical CT features, the most common was pulmonary cysts (n = 27 [9%]). The other features in the order of frequency included pleural effusion (5.7%), nodules (4.3%), bull's eye/target sign (1.3%), cavitation (1.0%), spontaneous pneumothorax (0.6%), hilar lymphadenopathy (0.6%), spontaneous pneumomediastinum with subcutaneous emphysema (0.3%), Halo sign (0.3%), empyema (0.3%), and necrotizing pneumonia with abscess (0.3%).

Hence, there are a multitude of causes of lung cavitations in a case of Post Covid-19 as enlisted in [Table 1].[13],[14],[15]
Table 1: Various causes of pulmonary cavities in post covid syndrome

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Cysts in other organs such as the liver[16] and spleen[17] due to infarction have also been reported following acute COVID.


  Conclusion Top


COVID-19 may independently result in pulmonary cyst formation with the development of a pneumothorax irrespective of the severity of the disease or the ventilator volutrauma and barotrauma. Thus, a pulmonary cyst should be considered in the differential diagnosis of a patient who has persistent respiratory complaints after recovering from acute COVID-19 syndrome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Clinical management protocol for covid-19 in adults as of 24 May 2021. https://www.mohfw.gov.in/pdf/revisedhomeisolationguidelines.pdf,  Back to cited text no. 1
    
2.
Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F. et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in covid-19. N Engl J Med 2020; 383:120-128.  Back to cited text no. 2
    
3.
Klok FA, Kruip MJ, van der Meer N, Arbous MS, Gommers D, Kant KM, et al. Confrmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: an updated analysis. Thromb Res 2020;191:148-150.  Back to cited text no. 3
    
4.
Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-147.  Back to cited text no. 4
    
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Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020;395(10234):1417-1418.  Back to cited text no. 5
    
6.
Lax SF, Skok K, Zechner P, Kessler HH, Kaufmann N, Koelblinger C, et al. Pulmonary arterial thrombosis in COVID-19 with fatal outcome: results from a prospective, single-center, clinicopathologic case series. Ann Intern Med. 2020;173(5):350-361.  Back to cited text no. 6
    
7.
Angirish B, Parmar K (2020) Lung cavitation-a rare complication in COVID-19 patients: A case report. Arch Pulmonol Respir Care 6(1): 078-080. DOI: https://dx.doi.org/10.17352/aprc.000061  Back to cited text no. 7
    
8.
Nowak MD, Sordillo EM, Gitman MR, Paniz Mondolfi AE. Co-infection in SARS-CoV-2 infected Patients: Where Are Influenza Virus and Rhinovirus/ Enterovirus? J Med Virol. 2020; April 30. doi: 10.1002/jmv.25953. [Epub ahead of print].  Back to cited text no. 8
    
9.
Kim D, Quinn J, Pinsky B, Shah NH, Brown I. Rates of Co-infection Between SARS-CoV-2 and Other Respiratory Pathogens. JAMA. 2020;323(20):2085-6.  Back to cited text no. 9
    
10.
Amaral LT, Beraldo GL, Brito VM, Rosa ME, Matos MJ, Fonseca EK, et al. Lung cavitation in COVID-19: co-infection complication or rare evolution? einstein (São Paulo). 2020;18: eAI5822. http://dx.doi.org/10.31744/ einstein_journal/2020AI5822  Back to cited text no. 10
    
11.
Kruse JM, Zickler D, Lüdemann WM, Piper SM, InkaGotthardt, et al. Evidence for a thromboembolic pathogenesis of lung cavitations in severely ill COVID 19 patients. Scientifc Reports; (2021) 11:16039; https://doi.org/10.1038/s41598-021-95694-0  Back to cited text no. 11
    
12.
Gurumurthy B, Das SK, Hiremath R, Shetty S, Hiremath A, Gowda T. Spectrum of atypical pulmonary manifestations of COVID-19 on computed tomography. Egyptian Journal of Radiology and Nuclear Medicine (2021) 52:72 https://doi.org/10.1186/s43055-021-00448-7  Back to cited text no. 12
    
13.
Marchiori E. Clinical Imaging https://doi.org/10.1016/j.clinimag. 2021.04.038.  Back to cited text no. 13
    
14.
Zoumot, Z., Bonilla, MF., Wahla, A.S., Shafiq I., Uzbeck M., El-Lababidi RM, et al. Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease. BMC Pulm Med 21, 24 (2021). https://doi.org/10.1186/s12890-020-01379-1.  Back to cited text no. 14
    
15.
Selvaraj V, Dapaah-Afriyie K. Lung cavitation due to COVID-19 pneumonia. BMJ Case Rep. 2020;13(7):e237245. Published 2020 Jul 6. doi:10.1136/bcr-2020-237245.  Back to cited text no. 15
    
16.
D'Amico FE, Glavas D, Noaro G, Bassi D, Boetto R, Gringeri E, De Luca M and Cillo U (2021) Case Report: Liver Cysts and SARS-CoV-2: No Evidence of Virus in Cystic Fluid. Front. Surg. 8:677889. doi: 10.3389/fsurg.2021.677889.  Back to cited text no. 16
    
17.
Santos Leite Pessoa M, Franco Costa Lima C, Farias Pimentel AC, Godeiro Costa JC, Bezerra Holanda JL. Multisystemic Infarctions in COVID-19: Focus on the Spleen. Eur J Case Rep Intern Med. 2020;7(7):001747. Published 2020 Jun 3. doi:10.12890/2020_001747.  Back to cited text no. 17
    

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Correspondence Address:
Taseena Banu Rehman,
Department of Medicine, MVJ Medical College and Research Centre, Hoskote, Bengaluru - 562 114, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajim.ajim_95_21



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