Annals of Internal Medicine
CLINICAL CASES
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doi/10.7326/aimcc.2022.0357
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Publication date: 16 May 2023
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Corresponding Author
Utku Ekin, MD; Department of Internal
Medicine, St. Joseph’s University Medical
Center, 703 Main St., Paterson, NJ 07503;
e-mail, utkuekin@gmail.com.
How to Cite
Ekin U, Millet C, Chaudhry S, et al.
Successful management of spontaneous
pneumatocele and pneumothorax
formation after COVID-19 infection. AIM
Clinical Cases. 2023;2:e220357.
doi:10.7326/aimcc.2022.0357
1/4
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CASE REPORT
Successful Management of Spontaneous Pneumatocele and
Pneumothorax Formation After COVID-19 Infection
Utku Ekin, MD1 ; Christopher Millet, DO1 ; Sohail Chaudhry, MD1 ; Christopher Biggiani, MD1 ;
Arslan Chaudhry, MD1 ; and Justin Thorson, MD1
1 Department
of Internal Medicine, St. Joseph’s University Medical Center, Paterson, New Jersey
Keywords
COVID-19, Thorax, Lungs, Pneumonia, Etiology, Ventilators, Surgery, Inflammation, Computed axial
tomography, Positive-pressure ventilation
Abstract
Pneumatoceles are rarely encountered in the clinical setting. Very few cases have been
documented that involved COVID-19 pneumonia as a cause. Furthermore, even fewer cases
document spontaneous pneumothorax complicating the pneumatocele that required urgent
intervention. We present a case of a patient who developed a pneumatocele as a complication
of symptomatic COVID-19 infection. The patient’s clinical course was further complicated by
spontaneous pneumothorax formation. The patient had thoracostomy and video-assisted
thoracoscopic surgery. Here we describe the patient’s clinical course in detail.
Background
It has been more than 2 years since the COVID-19 pandemic began. We now know some of the
common complications that have been reported, such as pneumonia, acute respiratory distress
syndrome, acute liver injury, cardiac injury, acute heart failure, arrhythmias, myocarditis,
and prothrombotic coagulopathy, resulting in venous and arterial thromboembolic events,
acute kidney injury, and neurologic manifestations (1). Pulmonary pneumatoceles are cystic
spaces that develop in the lung and are encountered in rare circumstances. To date, there have
been very few reported cases of spontaneous pneumatocele and subsequent pneumothorax
formation due to COVID-19.
Most cases of pneumatoceles are asymptomatic and often occur after insult to the lung
parenchyma, such as bacterial or viral pneumonia. Although pneumatoceles are predom-
inantly infectious in cause, they may develop from other pathophysiologic mechanisms,
including trauma, positive-pressure ventilation, surgery, hydrocarbon or kerosine ingestion (and
inhalation), burns, and diffuse interstitial pulmonary emphysema. Some of the radiographic
features may make it indistinguishable from a cavitating lung mass or an abscess (2–4). Here,
we report a case of a patient who developed COVID-19 complicated by a pneumatocele and
pneumothorax, requiring urgent intervention.
Objective
This case outlines the medical and surgical management of a patient with a sizable pneuma-
tocele and its severe complication of a spontaneous pneumothorax.
Case Report
A 43-year-old woman with a medical history of hypertension presented to the emergency
department (ED) with complaints of shortness of breath and cough. The patient tested positive
for SARS-CoV2, and a radiograph of the chest revealed a consolidative infiltrative process in the
right middle lobe. The patient was discharged home in stable condition. The patient presented
to the ED 7 days later with progressive shortness of breath, cough, and fevers and was admitted
for treatment of COVID-19 pneumonia. Radiograph of the chest showed a sizeable new bulla
in the right upper lobe not previously visualized (Figure 1). The patient underwent a computed
tomography (CT) angiogram scan of the thorax to rule out a pulmonary embolism in the setting
of persistent hypoxia and tachycardia. This scan ruled out pulmonary embolism; however,
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Successful Management of Spontaneous Pneumatocele and Pneumothorax Formation ... Ekin et al. Annals of Internal Medicine: Clinical Cases e220357 (2023)

Figure 1. Initial radiograph of the chest demonstrated a large bulla of the

upper lobe of the right lung. Orange arrows point to the inferior border of the Figure 3. Chest radiograph demonstrates right-sided pneumothorax. Orange
bulla. Some lung tissue markings can be seen behind the air-filled space. arrows point to the collapsed lung border.

it exhibited a large right-sided pneumatocele occupying a
significant portion of the right hemithorax (greater than 50%
of the right hemithorax) (Figure 2). The patient was discharged
after completing treatment of COVID-19 and planned for an
outpatient follow-up with video-assisted thoracoscopic surgery
(VATS) due to the large size of the pneumatocele and the risks for
further complications.
Two days before her scheduled procedure, the patient returned
to the ED with severe right-sided chest pain and shortness of
breath. Radiograph of the chest exhibited a new right-sided
pneumothorax (Figure 3). A noncontrast CT scan of the thorax
demonstrated a moderate-sized right pneumothorax and a large
right pneumatocele (Figure 4). The cardiothoracic surgery team
was consulted, and the patient had a right-side thoracostomy.
Radiograph of the chest showed slight reexpansion of the right
lung and a mild decrease in the size of the pneumothorax. The
chest tube was connected to water seal, and there was initially
no air leak. However, on the third day of admission, a persistent
small air leak appeared, and subsequent radiographs of the
chest demonstrated there was no change in the size of the pneu-
mothorax, which prompted the surgeons to proceed with VATS.
Several days later, the patient had a VATS procedure, which
revealed a great amount of intrapleural adhesions and a large
right-upper-lobe pneumatocele. The procedure consisted of

Figure 2. A computed tomography angiogram of the thorax demonstrates a large right-sided pneumatocele. Ground-glass opacities are appreciated in the
remaining lung parenchyma bilaterally.

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Successful Management of Spontaneous Pneumatocele and Pneumothorax Formation ... Ekin et al. Annals of Internal Medicine: Clinical Cases e220357 (2023)

Figure 4. Computed tomography of the thorax demonstrates large pneumatocele of the right lung as well as pneumothorax with collapsed portions of the right
lung. Orange arrows point to the thin wall of the pneumatocele.

resecting the pneumatocele, right-upper-lobe wedge resection,
intrathoracic lysis of adhesions, and insertion of 2 chest tubes.
Histopathologic analysis was performed, which showed changes
consistent with acute-on-chronic inflammation, cryptogenic
organizing pneumonia, and acute fibrinous pleuritis. Two
days after the procedure, radiograph of chest demonstrated
improvement of the pneumothorax. Four days after surgery,
the chest tubes were removed, and a small residual pneu-
mothorax remained stable. She was discharged home in stable
condition.
Discussion
Spontaneous pneumatocele and pneumothorax are rare compli-
cations of COVID-19. Pneumatoceles, otherwise known as pseu-
docysts, are thin-walled air-filled cysts that develop within the
lung interstitium. These cysts result from an inflammatory
response in the bronchus, leading to the formation of an
endobronchial ball valve in which air cannot exit the bronchus.
This results in distal dilation of the bronchi and alveoli and
air-trapping. The pneumatocele can further expand from either
another pneumatocele or from inflammatory exudates. They
may also be single or multiple. The presentation may include
hemoptysis in more than one-half of the cases, followed by chest
pain and cough (4, 5).
Regardless of the cause, CT imaging remains the best method in
identifying pneumatoceles, with the appearance being a round
or oval thin-walled cavitary lesion with occasional air-fluid levels.
Radiography can also help in detecting pneumatoceles (4). With
regards to treatment, most cases of pneumatocele resolve spon-
taneously and do not require surgical intervention. Conservative
management is generally the cornerstone of therapy, especially
if the patient is hemodynamically stable. The resolution may take
several weeks to months, and follow-up radiography of the chest
is recommended until resolution occurs (6). Severe cases that
result in a pneumothorax require immediate intervention. In
some instances, pneumatoceles may cause a mass effect on the
mediastinum or surrounding lung tissue and necessitate surgical
intervention (4).
VATS may be indicated when there is a prolonged air leak after
tube thoracostomy, the presence of hemothorax or large pneu-
mothorax (as in our patient), failure of lung expansion, enlarging
character, and having the pneumatocele compress nearby
organs (4). Although no clear-cut guidelines exist for surgical
approaches to pneumatoceles, previous studies have demon-
strated the benefits of earlier surgical intervention, as ruptured
pneumatoceles can result in mortality (7). In patients who are
stable, conservative and nonemergent management is the
cornerstone of therapy; however, in the setting of complicated
pneumatoceles that occupy greater than 50% of the hemithorax,
an earlier surgical treatment approach may prove to be more
beneficial (6, 8). Thus, our patient was initially offered outpatient
follow-up with surgical treatment for several reasons. First,
the large size of the pneumatocele occupying more than
one-half of the hemithorax increases the risk for complications.
Second, there is the risk for pneumatocele rupture, causing
tension pneumothorax, which can be fatal. Third, there is
the risk for enlargement of the pneumatocele, compressing
nearby structures and causing cardiovascular compromise
(that is, tension pneumatocele) (8). After the procedure, the
histopathology typically demonstrates extensive alveolar
hemorrhage, interstitial inflammation, fibrotic changes, and
organizing pneumonia (9, 10). Typically, most reported cases

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Successful Management of Spontaneous Pneumatocele and Pneumothorax Formation ... Ekin et al.
were due to a combination of infection and positive-pressure
ventilation that had led to pneumatocele formation (9, 11, 12).
Surgical intervention is relatively safe, with a 77% survival
rate for patients with COVID-19 complications such as pneu-
mothorax, empyema, and pneumatocele (13). In the case of our
patient, a surgical approach was beneficial and yielded a positive
outcome. The ultimate decision for surgery should be made after
an appropriate risk assessment of potential complications from
the pneumatocele and an informed discussion between the
patient and the provider.
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