PMC7527682_01
The progression of SARS-CoV2 previous to being transferred to our department. a) CT-scan showing focal consolidation with ground-glass peribronchovascular changes. b) CT-scan 1 month later showing perilobular consolidation and reverse Halo-sign, similar to organizing pneumonia and newly appeared cystic lesions. c) CT-scan showing spontaneous pneumothorax. d) X-ray image showing the extend of pneumothorax (blue arrows) and two chest tubes (green and white arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).
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Subsequently, he was diagnosed with COVID-19 after a CT scan (Fig. 1a) showed typical COVID-19 associated findings including ground-glass consolidation and crazy-paving pattern although two nasopharyngeal swabs showed negative PCR results. The patient had a prolonged course of disease with recurrent sub-febrile temperatures, fluctuating inflammatory blood parameters, anosmia and dysgeusia, constant oxygen dependency and increasing inflammatory changes on CT scan (Fig. 1b). 22 days later a singular dose of tocilizumab 800 mg was administered followed by a fast subjective improvement of the patient's clinical condition. However, on day 26 he developed a spontaneous pneumothorax on his left side (Fig. 1c), which was initially drained with a 12-French chest tube. After initial re-expansion, the patient suffered from recurrent pneumothorax 5 days later (Fig. 1d).
Intraoperative images from the two first thoracoscopies. On the left side: a) prominent ruptured bulla (consecutively resected). b) adhesions and cauliflower like rearrangement of lung tissue. Procedure 2 on the right side: c) blood filled bulla (consecutively resected). d) cauliflower like rearrangement of lung tissue.
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A bulla-like lesion filled with hematoma on segment 6 (Fig. 2a) was observed. The entire lung was covered with a thin layer of fibrin deposits and showed several cauliflower-like scarred lesions, possibly corresponding to the COP like lesions seen on CT (Fig. 2b). No active air leak was found, but the lower lobe showed again a bulla-like hematoma (Fig. 2c). Scarred lesions were found on the lower and middle lobe (Fig. 2d).
a) Microscopic picture of the resected lung tissue with defined area of atelectatic lung with intra-aleveolar hemorrhage and subpleural hematoma. (Hematoxylin Eosin staining (HE), 50x magnification). b) residual endotheliitis in small and medium sized vessel and intra-alveolar polypoid fibroblast plugs specifying organizing pneumonia (HE, 200x magnification). c) CT-scan showing spontaneous pneumothorax on the right side and residual ground-glass opacities. d) final X-ray about 5 weeks after hospitalization showing a fully re-expanded lung.
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Six days later the patient developed a spontaneous pneumothorax on the right side (Fig. 3c) and was directly scheduled for thoracoscopy. The histology of the resected material from both sides showed fibrotic tissue, fibrinous inflammatory changes, intra-alveolar hemorrhage and reactive mesothelial changes as well as endothelitis (Fig. 3a and b). The final X-ray after removal of the permanent pleural catheter showed a fully expanded lung (Fig. 3d).