C50-03 Atypical Progression From Pneumopericardium to Pneumomediastinum in Severe Covid-19: A Rare Clinical Course

Abstract Background Spontaneous pneumothorax is an uncommon complication of severe COVID-19 pneumonia, arising from barotrauma and progressing to pneumomediastinum and, occasionally, pneumopericardium. We report an unusual case demonstrating the uncommon sequence of initial pneumopericardium followed by pneumomediastinum and pneumothorax, highlighting a unique pathophysiological progression. Case Presentation A 75-year-old man with a history of type 2 diabetes mellitus, hypertension, and prior tobacco use presented with progressive dyspnea and tested positive for SARS-CoV-2. Initial non-contrast CT chest revealed bilateral ground-glass opacities and interstitial infiltrates. Within 24 hours, his respiratory function deteriorated, with oxygen requirement escalated to high-flow nasal cannula (Airvo). Repeat imaging showed worsening pulmonary findings. He was treated with intravenous dexamethasone and broad-spectrum antibiotics. After initial improvement on IV steroids and step-down to nasal cannula, he was discharged to a long-term acute care facility (LTAC). On day of initial diagnosis, he experienced sudden respiratory decompensation. CT imaging revealed a new pneumopericardium along with progression of infiltrates. He was transferred to the ICU, intubated with low positive end-expiratory pressure (PEEP), and restarted on high-dose steroids and antibiotics. Despite conservative ventilation settings with lowest PEEP possible, subsequent imaging demonstrated the emergence of pneumomediastinum and bilateral pneumothoraces, with worsening pneumopericardium. Patient deemed to be poor candidate for intervention by cardiothoracic surgery. Despite maximal aggressive care, the patient’s respiratory status continued to decline. After discussion with the family, care was transitioned to comfort measures. Discussion While pneumothorax and pneumomediastinum have been reported in COVID-19, this case is unique in presenting with an initial pneumopericardium, followed by sequential development of pneumomediastinum and pneumothoraces. The temporal evolution observed in this case underscores the unpredictable nature of COVID-19-related barotrauma, even in the absence of high ventilatory pressures. Multiple sequential CT scans were crucial in delineating this progression and guiding management. The case also raises caution regarding mechanical ventilation, which may exacerbate underlying alveolar damage and contribute to these complications. Conclusion Clinicians should remain vigilant for atypical clinical courses in COVID-19 pneumonia, including rare presentations such as pneumopericardium preceding pneumothorax. Early imaging and conservative ventilation strategies may help mitigate progression in high-risk patients. This abstract is funded by: None