PMC7415109_01
CXR with different infiltrates patterns during the initial 24 hours. (a) Initial CXR at the ED revealing bilateral pleural effusions with bibasilar consolidation, increased interstitial markings suggestive of bilateral pulmonary edema, and enlarged cardiac silhouette. (b) After endotracheal intubation with increased confluent airspace opacities throughout the mid-to-lower lungs, findings suggestive of worsening pulmonary edema vs. multifocal infectious process. (c) Findings with the tip of the endotracheal tube overlying the proximal right mainstem bronchus. Otherwise; the bilateral diffuse confluent airspace opacities are not significantly changed. Tube was retracted 2 cm. (d) Ten hours after initial CXR revealing stable cardiomegaly, persistent bilateral fluffy infiltrates and consolidation, and persistent obscuration of the right hemidiaphragm.
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Sequential chest X-ray (CXR) during the first 24 hours did not correlate with the degree of hypoxemia (Figure 1). She was immediately transferred to the ICU, requiring vasopressors and ventilatory support, demanding constant adjustments to the ventilator settings.
TTE showing a free-flowing pericardial effusion identified circumferentially to the heart. Mild decrease of her left ventricular systolic function, from 50% in January 2020 to 40-45%. (a) Parasternal short axis view. (b) Subxiphoid view.
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Additionally, a transthoracic echocardiogram (TTE) performed the same day revealed reduced ejection fraction (EF) estimated at 40-45% and a new free-flowing pericardial effusion (Figure 2).
Computed tomography of the Chest. (a-c) Large right pneumothorax with small pneumomediastinum and mediastinal shift compatible with tension pneumothorax (unidentified on daily CXR). Diffuse ground-glass opacities with dense consolidations in both inferior lobes, early fibrosis in the right middle lobe, and multiple pneumatoceles. (d) Acute segmental pulmonary embolism is noted in the posterior segment of the right lower lobe.
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After 30 days, a computed tomography (CT) of the chest confirmed a segmental pulmonary embolism, along with a large right pneumothorax, small left pneumomediastinum, and leftward mediastinal shift (Figure 3), which were not observed in daily CXR (Figure 4).
CXR progression until tracheostomy and chest tube insertion. Overall images were remarkable for stable appearance of subtle ill-defined hazy opacities throughout both mid to lower lungs. Infiltrates were always most accentuated in the left lung. No evidence of obvious pneumothorax or pneumomediastinum.
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After 30 days, a computed tomography (CT) of the chest confirmed a segmental pulmonary embolism, along with a large right pneumothorax, small left pneumomediastinum, and leftward mediastinal shift (Figure 3), which were not observed in daily CXR (Figure 4).