American Journal of Emergency Medicine 38 (2020) 2218

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A more realistic relationship between covid 19 and hemopneumothorax

included noninvasive positive pressure ventilation subcutaneous enoxaparin, and aspirin 81 mg/day. Subsequently, he experienced

an episode of hemoptysis, followed by increasing breathlessness.

Chest radiography was consistent with hydropneumothorax. Chest

Even though the recent report documented the occurrence of hemopneumothorax in a patient who tested positive for covid 19 infec- tion [1], the most likely underlying cause of hemopneumothorax in this patient was rupture of a vascular bulla, also exemplified by one of the cases previously reported by Ng et al. [2].

In the context of covid 19 infection a predisposing factor for hemopneumothorax could be the increased risk of pulmonary throm- boembolism associated with covid 19 infection [3], compounded by the hemorrhagic risk associated with anticoagulant therapy.

In its own right, even in the absence of prior anticoagulant therapy, pulmonary embolism can be complicated by hemopneumothorax [4]. This complication was reported in a 57 year old woman who presented with increasing breathlessness and hypoxemia. Chest radiography showed a right lower lobe cavitating lesion and right pneumothorax with an associated with an air-fluid level in that pleural space. Com- puted tomography pulmonary angiography showed pulmonary embo- lism involving the right descending pulmonary artery. Subsequent multiplanar reformatted computed tomography showed Filling defects in the right ascending and right descending pulmonary arteries, and also in the left ascending pulmonary artery. Ultrasound-guided percuta- neous drainage yielded an initial amount of 500 ml frank Hemorrhagic fluid. Subsequent chest aspirations yielded purulent fluid believed to be attributable to secondary infection of the hemopneumothorax. The final diagnosis was that of pulmonary embolism complicated by cavitat- ing pulmonary infarction and subsequent hemopneumothorax [4].

The role of anticoagulant therapy in the aetiopathogenesis of hemopneumothorax was exemplified by an 81 year old ex-smoker with documented bullous emphysema. He had been admitted to hospi- tal with a provisional diagnosis of acute exacerbation of chronic obstruc- tive pulmonary disease and unstable angina. His initial management

drainage yielded frank blood, thereby validating a diagnosis of hemopneumothorax [5].

In view of these observations [4,5], the occurrence of covid 19-related pulmonary embolism could be a risk factor for hemopneumothorax.

Declaration of Competing Interest

I have no funding, and no conflict of interest.

References

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3. Llitjos J-F, Leclerc M, Chochois C, Monsallier J-M, Ramakers M, Auvray M, et al. High

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   Raghavan R, Ellis AK, Wobeser W. Hemopneumothorax in a COPD patient treated

   with noninvasive positive pressure ventilation: the role of antecedent anticoagulation. Can Respir J. 2004;11:158-62.

   Oscar M.P. Jolobe MRCP(UK)

   Medical division, Manchester Medical Society, Simon Building, Brunswick

   Street, Manchester M13 9PL, UK E-mail address: oscarjolobe@yahoo.co.uk

   11 August 2020

   https://doi.org/10.1016/j.ajem.2020.09.016

   0735-6757/(C) 2020