Case 5
A 51-year-old man with past medical history of type-2 diabetes had worsening COVID-19 pneumonia and ARSA requiring intubation on day 10. He developed sepsis and multi-organ dysfunction. He was managed with antiviral, antibiotics, Tocilizumab and steroids. Two days after intubation, his CXR showed left side subcutaneous emphysema and signs of pneumomediastinum. His ventilator settings were CMV mode with tidal volume 390, PEEP 8 and Fio2 of 50%. During his course in ICU, he went into severe sepsis, MODS requiring antibiotics, antivirals, and steroids. He also showed signs of cytokine storm requiring IL-6 antagonist Tocilizumab.
CT showed extensive pneumo-mediastinum and subcutaneous emphysema with mild pneumo-thoraces bilaterally. The surgical emphysema extended into the neck. The pneumo-mediastinum extended into the abdomen and appeared anteriorly in the extraperitoneal region. Bilateral segmental branches of the main pulmonary arteries, going towards the lower lobes, showed filling defects.
As he also had significant pneumothorax, the right-sided chest tube was inserted. A few hours later, he had cardiac arrest due to refractory hypoxia requiring ECMO support. He responded to the management and was decannulated from ECMO after 29 days. His sputum grew Enterococcus fecalis , Klebsiella , and Serratia marcescens . He recovered after a prolonged course in ICU and was discharged for rehabilitation.
All five cases key lines are presented in table1.