Case 4
A 63-year-old man with a past medical history of type-2 diabetes,
diabetic nephropathy presented with sudden deterioration of cognitive
function, generalized fatigability, and hematuria. He was COVID-19
positive upon admission. His MRI showed infratentorial microhemorrhages.
His condition deteriorated and he developed COVID-19 pneumonia and ARDS
requiring intubation on day 18 of admission. He was managed with
antiviral, antibiotics, as he also showed signs of cytokine storm
requiring IL-6 antagonist Tocilizumab and steroids. 10 days after
intubation, his CXR showed signs of pneumoperitoneum and anterior
extraperitoneal air. The ventilator settings included pressure control
mode with Fio2 60%, PEEP 8, pressure control 32 and respiratory rate of
28/min. His sputum culture was growing Klebsiella , Candida
albicans , and Serratia marcescens .
CT scan showed evidence of mild lower neck surgical emphysema more to
the right lateral side. Extensive tension pneumo-mediastinum was noted
extending from the superior mediastinum, down anteriorly and posteriorly
to the pre-crural and pre-cardiac space causing cardiac tension. This
pneumo-mediastinum extended inferiorly to the anterior retroperitoneal
space. No intraperitoneal free air was seen. Diffuse mosaic ground-glass
attenuation of both lungs was noted which was consisted with ARDS.
Pneumomediastinum was managed conservatively and he recovered from this.
Later he developed severe sepsis, multi-organ dysfunction and lung
fibrosis and unfortunately expired one month later.