Bronchopleural fistula and bilateral pneumothorax in a patient with COVID‐19

Abstract COVID‐19 pneumonia causes several complications that include pneumothorax, hydropneumothorax, empyema, and rarely leads to bronchopleural fistula (BPF). BPF is a communication between the pleural space and the bronchial tree. We report a case of 24 years man with pneumothorax, hydropneumothorax, and BPF that appeared after COVID‐19 infection.

On examination, patient was ill looking, conscious, and was well oriented to time, place, and person. He had pulse rate 110 beats/minute, respiratory rate 25/min, blood pressure 124/80 mm of Hg, and temperature was 98°F. He had no pallor, icterus, lymphadenopathy, cyanosis, or clubbing. There was bilateral decrease in air entry on chest auscultation over 4th and 5th intercostal spaces which was more on the left side. He had bronchial breath sounds bilaterally.
Chest X-ray showed bilateral consolidation of lungs in the middle zone ( Figure 1). High-resolution computed tomography (HRCT) of chest revealed bilateral multiple cavitary lesions with diffuse patchy ground-glass opacification, thickened interlobular septa, bilateral lower lobe consolidation, traction bronchiectatic changes, and bilateral pleural effusion with passive atelectasis and mediastinal lymphadenopathy. There was cystic bulla communicating with pleura in the left side. Pleural fluid tapping was done under aseptic conditions with ultrasonography (USG) guidance, and 18 ml of serosanguinous fluid was aspirated. However, there was no growth of bacteria in it.
Based on the radiological findings, diagnosis of leftsided hydropneumothorax, right-sided pneumothorax, and bronchopleural fistula (BPF) on left side was made. Following this, bilateral chest tube was inserted to treat left side hydropneumothorax and right side pneumothorax. He developed fever after 5 days of hospital stay for which culture of the pleural fluid was done that revealed the growth of Acinetobacter lwoffi. He was treated with (piperacillin +tazobactum [4.5 g IV QID], linezolid [600 mg BD], montelukast [10 mg OD], and hydrocortisone [100 mg IV BD]) for 14 days. Repeat chest X-ray was normal following which, chest tube was removed. He improved clinically and was discharged on oral medications (amoxicillin and clavulanic acid [625 mg TDS] for 7 days, azithromycin [500 mg OD] for 5 days, and montelukast [10 mg OD] for 7 days). His follow-up was not eventful.

| DISCUSSION
Necrotizing lung infections, post-lung resection, and chemoradiation therapy are the common causes of BPF. 1 The overall mortality rate of BPF is between 25% and 71%. 1 Pleural space infection, hypoxia, and inadequate lung expansion are common complications of recurrent air leakage. 1 The pathophysiology of BPFs in SARS-CoV-2 is unknown; however, there are few case reports describing cavitary lung lesions as a cause of BPFs. 2 Intra-alveolar bleeding, which leads to additional parenchymal cell necrosis, as corroborated by postmortem studies can also be correlated with the cavitation in the lungs. 3 The radiological investigation of choice for diagnosing BPF is contrast-enhanced chest computed tomography. 4 Bronchoscopy is the gold standard for diagnosing and localizing BPF, with progressive balloon occlusion allowing for real-time assessment of air leak site. 4,5 Because persistent BPF is usually caused by pleural infection, the choices of treatment are chest tube drainage and longterm antibiotics. 4 Large BPFs (>8 mm in diameter) are treated surgically. 4 Endobronchial intervention is preferred in high-risk surgical candidates to avoid the risk of surgery and for management of smaller fistulas. 5 Patients with BPF due to causes other than lung resection, such as our patient with SARS-CoV-2 pneumonia, are treated with bronchoscopy with endobronchial valves, as surgical closure of a BPF is likely to fail due to friable lung tissue. 4,5 Endobronchial procedures may also include the use of sealing agents such as glues or an autologous blood patch. F I G U R E 1 Chest X-ray showing bilateral consolidation of lungs Endobronchial occlusion is a less invasive alternative to thoracic surgery for treating BPFs. 6,7 However, the treatment of pneumothorax or empyema along with bronchial fistula secondary to COVID-19 pneumonia has not been discussed in literatures. In our situation, the chest tube effectively drained pleural cavity without a septal wall. As a result, pleural cavity debridement surgery was not done.

| CONCLUSION
Bronchopulmonary fistula is one of the rare complications of COVID-19. Clinicians should be aware of this scenario, which can be treated with bronchoscopy procedures like EBV or sealing the fistula with glues or blood patch or even surgery for severe cases. In our patient, chest tube was sufficient for the treatment without the complications.