Journal of Current Biomedical Reports  jcbior.com 

Volume 2, Number 4, 2021                                                                                                          eISSN: 2717-1906 

1 

Case report 

Pneumomediastinum, pneumopericardium pneumothorax and 
subcutaneous emphysema in Iranian COVID-19 patients 

 

Manouchehr Aghajanzadeh1, Mohammad Haghighi2,*, Siamak Rimaz2, Ali Alavi Fomani3, Azita 
Tangestaninejad3, Mohammad Taghi Ashoobi3, Yousha Pourahmadi3, Mohammad Mojtaba Rohani4 

 
1Department of Thoracic Surgery, Guilan University of Medical Sciences, Rasht, Iran 

2Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran 
3Inflammatory Lung Diseases Research Center, Department of Internal Medicine, Razi Hospital, School of Medicine, Guilan University 

of Medical Sciences, Rasht, Iran 
4Department of Radiology, Razi Hospital, Guilan University of Medical Science, Rasht, Iran 

 

Abstract 
Recently, spontaneous pneumomediastinum (PM), pneumopericardium (PP), pneumothorax (PT), and 
subcutaneous emphysema (SE) were reported as infrequent complications in coronavirus disease 2019 
(COVID-19) patients in intensive care (ICU). Here we report these complications in nine Iranian 
patients of COVID-19. Nine patients with reported PM, PP, PT, and SE in COVID-19 who were 
hospitalized in Arya hospital, Rasht, Iran, for three months, were followed to record demographic data 
and clinical characteristics of these patients. In nine PM-developed patients, six cases represented PT, 
one patient with PP, and four patients with PT and SE. Four patients expired and only five patients 
survived. PM, PP, PT, and SE are uncommon complications in COVID-19 patients and were reported 
frequently in male patients. Early diagnosis and treatment could save the patients since these 
complications are related to poor prognosis and prolonged hospitalization. Patients with mild COVID-
19 and mild pulmonary damage have a favorable outcome.  

Keywords: COVID-19, Subcutaneous emphysema, Spontaneous pneumomediastinum, Pneumopericardium, 
Pneumothorax 

 
1. Introduction  
Severe acute respiratory syndrome coronavirus-2 

(SARS-CoV-2) infection has developed as the greatest 
pandemic in this era with high morbidity and 
mortality and multiple complications. There are lots of 
review studies about coronavirus disease 2019 
(COVID-19) and its complications [1-4]. Irregular 
reported numbers of spontaneous 
pneumomediastinum (PM), pneumopericardium 
(PP), pneumothorax (PT), and subcutaneous 
emphysema (SE) cases in patients with COVID -19, 
and also in the patients without mechanical 

                                                           
*Corresponding author:  
Mohammad Haghighi, MD 
Department of Anesthesiology, Alzahra Hospital,  
Guilan University of Medical Sciences, Rasht, Iran  
Tel/Fax: +98 911 3315256 
Email: manesthesist@gmail.com 
http://orcid.org/0000-0003-0331-1683 
 
Received: September, 15, 2021 
Accepted: December, 14, 2021 

ventilation, which results in barotrauma [5]. The 
pathophysiologic mechanism of PM is an increased 
gradient pressure between the alveoli and 
parenchyma of lung that leads to severe alveolar injury 
and the air dissects the surrounding bronchovascular 
sheaths, and this air enters into the mediastinum and 
produces PM and disturbance to cervical SE and 
pleural space PT [3, 5, 6]. Alveolar wall is more prone 
to rupture due to inflammation in COVID-19 patients 
and alveolar wall is exacerbated by severe cough or any 
problems which increase the intra-alveolar pressure 
[5].  Invasive positive pressure ventilation can cause 

  © The Author(s) 2021 

https://jcbior.com/


Aghajanzadeh et al. 

2 

PT and/or PM spontaneously. Barotrauma is the 
cause of PM, PT, PP, and SE [3]. In this care report, we 
focus only on hospitalized COVID-19 patients who 
developed these complications. Some of patients have 
primarily mild to moderate disease condition, but 
deteriorated progressively, and also represented the 
associated factors to prognosis these complications. 

 
2. Case presentation  
In this case report, we evaluated case series and 

described the record of nine patients in Arya hospital, 
Rasht, Iran during three months in COVID-19 fourth 
outbreak from April until July 2020. Patients 
demographic data, medical histories, clinical and 
laboratory finding, chest computer tomography (CT) 
results, and patient’s outcome (death or discharged), 
were recorded. All subjects gave their informed 
consent to participate in the study. 

According to our evaluation, seven out of nine 
patients with COVID-19 were male and two of them 
were female. The age range was about 32 to 68 years 
by mean of 48.27±10. Diagnosis of COVID-19 was 
confirmed by polymerase chain reaction (PCR). 
Among nine patients, three of them reported the 
history of hypertension, four of them had type 2 
diabetes mellitus, two patients had bronchial asthma, 
and also two of them had obesity. After two to six days 
of hospitalization, all of the nine patients represented 
one or more following complications: PM, PP, PT, and 
SE. Three patients with low oxygen saturation 
(between 50% and 86%), improved up to 90–93% on 
BiPAP mask at 12 L/min. Chest CT was done to 
evaluate the severity of lung damaged due to SARS-
CoV-2 at the early stage (Supplementary Figures 1–8). 
The most common radiologic findings were ground-
glass pattern, integrated opacity, and thickening of 
septum. Four patients suffering minor pulmonary 
damage (10–35% of lung), three of them had 
moderate injury (50% of lung) and four cases had 
severe forms of injury (over 70% of lung). None of 
patients represented PM, PP, PT, or SE complications, 
while these complications happened after 1 to 8 days 
of hospitalization.  

Laboratory findings have revealed following data: 
the count of neutrophil increased but lymphocyte 
decreased, C reactive protein (CRP) was higher than 
100 mg/L, also the levels of ferritin and lactate were 
increased. Arterial blood gases evaluation was as 
follows: the mean of initially PO2 was 78 mmHg (59–

83), but later decreased to 54 mmHg (48–85). The 
mean of initially PCO2 was 60 mmHg (48–68), and 
the mean of and O2 saturation was 80.2% (60–98%). 
All patients were received one ceftriaxone course of 
treatment in combination with remdesivir, 
dexamethasone, and levofloxacin. Cardiothoracic 
surgeon consulted all cases. Throughout 
hospitalization, eight patients needed oxygen therapy, 
six patients were transferred to the intensive care unit 
(ICU), and underwent invasive ventilation. Six 
patients needed chest tube, and six patients with PT 
needed subclavicular incision for evacuation of SE, 
while the rest of them were managed conventionally. 
Four patients died after 8-20 days, with the median of 
6-12 days of hospitalization. The remaining five 
patients who had moderate lung damage at admission 
time, did not need surgical drainage and were 
discharged in good clinical condition after 
hospitalization (8-12 days). Clinical characteristics of 
all patients were explained in detail in Table 1.  

 
3. Discussion  
PM is presented in two types, benign or 

malignant, which in some patient it can be fatal [7]. 
Benign type of PM can turn to malignant forms, in the 
case of rapidly rise pressure in the mediastinum, which 
causes all spaces to closed with no way for air escape. 
Malignant PM could consequence mechanical 
obstruction and presents as pericardial tampon, 
especially in the present of cough. This event can 
interfere with the cardiovascular function and causes 
reduction in circulation volume and tension PT form 
[5, 8, 9], which none of the nine reported patients 
represented this complication. In some patients with 
PM, air can escape into route to the neck, 
retroperitoneum or to the right and left pleural space, 
and causes bilateral PT, which can turn into tension PT 
form [10]. A retrospective study has reported that 13 
patients with COVID-19 have developed SPM with or 
without PT and SE [5, 8, 9]. In this case report, no 
patient had isolated PT and some of these patients 
needed invasive positive pressure ventilation. 
Furthermore, none of reported patients have 
represent with retroperitoneal emphysema. 
Moreover, this case report has showed high level 
serum of LDH, which might be due to cellular damage. 
Also, severe diffuse alveolar damage causes of the 
alveolar damage, and air escape along the 
bronchoalveolar sheath and mediastinum space [8].



Aghajanzadeh et al. 

3 

          T
a
b

le
 1

. 
D

e
m

o
g
ra

p
h
ic

a
l 

a
n
d

 c
li

n
ic

a
l 

c
h
a
ra

c
te

ri
st

ic
s 

o
f 

p
a
ti

e
n

ts
 

 

P
a

ti
e
n

t 

b
y

 

n
u

m
b

e
r
 

G
e
n

d
e
r
 

A
g

e
 

y
e
a

r
 

P
u

lm
o

n
a

r
y

 i
n

ju
r
y

 

b
y

 C
T

 
P

T
 

P
M

 
P

P
 

S
E

 
H

R
 

O
2
sa

t 
T

y
p

e
2

 d
ia

b
e
te

s 

m
e
ll

it
u

s 

C
-

T
 

S
-C

-

I 
S

U
R

 
A

st
h

m
a

 
O

u
tc

o
m

e
 

1
 

M
 

6
4
 

7
0

%
 

Y
e
s 

Y
e
s 

N
o

 
Y

e
s 

6
8
 

8
8

%
 

Y
e
s 

Y
e
s 

Y
e
s 

N
o

 
Y

e
s 

D
e
a
th

 

2
 

M
 

6
1
 

5
8

%
 

N
o

 
Y

e
s 

N
o

 
Y

e
s 

8
2
 

6
7

%
 

N
o

 
Y

e
s 

N
o

 
N

o
 

N
o

 
D

e
a
th

 

3
 

M
 

3
4
 

7
0

%
 

N
o

 
N

o
 

Y
e
s 

Y
e
s 

1
0

0
 

8
0

%
 

N
o

 
N

o
 

Y
e
s 

Y
e
s 

N
o

 
D

e
a
th

 

4
 

M
 

5
7
 

6
4

%
 

Y
e
s 

Y
e
s 

N
o

 
Y

e
s 

9
5
 

6
0

%
 

Y
e
s 

Y
e
s 

Y
e
s 

N
o

 
N

o
 

D
e
a
th

 

5
 

F
 

6
8
 

2
8

%
 

Y
e
s 

Y
e
s 

N
o

 
Y

e
s 

7
0
 

9
2

%
 

Y
e
s 

Y
e
s 

N
o

 
N

o
 

N
o

 
D

is
c
h
a
rg

e
 

6
 

M
 

4
4
 

2
0

%
 

Y
e
s 

N
o

 
N

o
 

N
o

 
7

0
 

9
8

%
 

N
o

 
N

o
 

Y
e
s 

Y
e
s 

N
o

 
D

is
c
h
a
rg

e
 

7
 

M
 

6
2
 

5
5

%
 

Y
e
s 

Y
e
s 

N
o

 
Y

e
s 

1
2

0
 

6
0

%
 

N
o

 
Y

e
s 

Y
e
s 

N
o

 
Y

e
s 

D
is

c
h
a
rg

e
 

8
 

M
 

5
3
 

5
0

%
 

Y
e
s 

N
o

 
N

o
 

N
o

 
1

0
0
 

8
7

%
 

Y
e
s 

 
Y

e
s 

Y
e
s 

N
o

 
N

o
 

D
is

c
h
a
rg

e
 

9
 

F
 

3
8
 

2
5

%
 

Y
e
s 

N
o

 
N

o
 

N
o

 
7

5
 

9
0

%
 

N
o

 
N

o
 

N
o

 
N

o
 

N
o

 
D

is
c
h
a
rg

e
 

 C
T

: 
th

o
ra

x
 c

o
m

p
u
te

r 
to

m
o

g
ra

p
h

y
, 

P
T

: 
p

n
e
u

m
o

th
o

ra
x
, 

P
M

: 
p

n
e
u

m
o

m
e
d

ia
st

in
u

m
, 

P
P

: 
p

n
e
u

m
o

p
e
ri

c
a
rd

iu
m

, 
S

E
: 

su
b

c
u
ta

n
e
o

u
s 

e
m

p
h

y
se

m
a
, 

H
R

: 
h
e
a
rt

 r
a
te

, 
S

a
t 

O
2

: 

o
x

y
g
e
n
 s

a
tu

ra
ti

o
n
, 

C
-T

: 
c
h
e
st

 t
u
b

e
, 

S
-U

-I
: 

su
b

c
la

v
ic

u
la

r 
in

c
is

io
n
, 

S
U

R
: 

su
rg

e
ry

 



Aghajanzadeh et al. 

4 

A similar study, reported COIVD-19 patients that 
represented pneumothorax (PTX), PM, and SE 
spontaneously or after mechanical ventilation [11]. We 
observed the occurrence of these complications in nine 
patients. In these reported patients, four of them 
represented spontaneously complications without 
invasive mechanical ventilation, while other 
represented complications in patients with invasive 
mechanical ventilation. As reported in other studies 
with the majority of male gender, seven of patients 
were male and two of them were female. The 
pathophysiological mechanism of complications was 
air leakage through damage of alveolar walls by 
inflammation during of cytokine storm [5, 12-14]. 
Despite to some studies with low mortality rate, in this 
case report, patient’s mortality rate due to PM, PP, PT, 
and SE was four out of nine patients.  

PM, PP, PT, and SE are rare complications in 
severe COVID-19 pneumonia.These complications are 
contributed to poor prognosis and prolonged 
hospitalization. Patients with mild COVID-19 and 
mild pulmonary damage have a favorable outcome. 

 
 
Supplementary files 
Supplementary file 1. 
 
Acknowledgments 
We would like to thank all individuals who 

volunteered to participate in this study. Furthermore, 
thank you to hospital staff and specialists for assistance 
with conforming and recording cases. 

 
Authors’ contribution 
Concept and Study design: MA, MH, SR; Methods 

and experimental work: AA, AT, MTA; Results 
analysis and conclusions: MA, MH, YP; Manuscript 
preparation: MMR, AA, AT, MTA. All authors read 
and approved the final version. 

 
Conflict of interests 
No potential conflict of interest was reported by 

the authors. 
 
Ethical declarations 
All subjects gave their informed consent to 

participate in the study. Also, all methods were 
performed in accordance with the relevant guidelines 
and regulations. 

Consent for publication 
Written informed consent was obtained from the 

patients for publication of this case report. A copy of 
the written consent is available for review by the 
Editor-in-Chief of this journal. 

 
Availability of data and material 
Corresponding author (Mohammad Haghighi) is 

available in the case in requiring, and all data and 
tables, used in the manuscript are prepared originally 
by authors 

 
Financial Support 

Self-funded. 
 
References 

1. Hamad AM, Elmahrouk AF, Abdulatty OA. Alveolar air leakage 
in COVID-19 patients: Pneumomediastinum and/or 
pneumopericardium. Heart Lung. 2020; 49(6):881-2. 
2. Murillo Brito D, Villalva C, Simón A, Guisado-Clavero M. 
COVID-19 pneumonia associated with spontaneous 
pneumomediastinum and pneumopericardium. CTSNET. 
2020:12485831. 
3. Martinelli AW, Ingle T, Newman J, Nadeem I, Jackson K, Lane 
ND, et al. COVID-19 and pneumothorax: a multicentre 
retrospective case series. Eur Respir J. 2020; 56(5) :2002697. 
4. Elhakim TS, Abdul HS, Pelaez Romero C, Rodriguez-Fuentes Y. 
Spontaneous pneumomediastinum, pneumothorax and 
subcutaneous emphysema in COVID-19 pneumonia: a rare case 
and literature review. BMJ Case Rep. 2020; 13(12):e239489. 
5. Juárez-Lloclla JP, León-Jiménez F, Urquiaga-Calderón J, 
Temoche-Nizama H, Bryce-Alberti M, Portmann-Baracco A, et al. 
Spontaneous Pneumopericardium and Pneumomediastinum in 
Twelve COVID-19 Patients. Arch Bronconeumol. 2021; 57:86-8. 
6. Aghajanzadeh M, Dehnadi A, Ebrahimi H, Fallah Karkan M, 
Khajeh Jahromi S, Amir Maafi A, et al. Classification and 
Management of Subcutaneous Emphysema: a 10-Year 
Experience. Indian J Surg. 2015; 77(Suppl 2):673-7. 
7. Macklin MT, Macklin C. Malignant interstitial emphysema of 
the lungs and mediastinum as an important occult complication in 
many respiratory diseases and other conditions. 1944:281-358. 
8. Jougon JB, Ballester M, Delcambre F, Mac Bride T, Dromer CE, 
Velly JF. Assessment of spontaneous pneumomediastinum: 
experience with 12 patients. Ann Thorac Surg. 2003; 75(6):1711-4. 
9. Sun R, Liu H. Mediastinal Emphysema, Giant Bulla, and 
Pneumothorax Developed during the Course of COVID-19 
Pneumonia. Korean J Radiol. 2020; 21(5):541-4. 
10. Chu CM, Leung YY, Hui JY, Hung IF, Chan VL, Leung WS, et 
al. Spontaneous pneumomediastinum in patients with severe 
acute respiratory syndrome. Eur Respir J. 2004; 23(6):802-4. 
11. Wadhawa R, Thakkar A, Chhanwal HS, Bhalotra A, Rana Y, 
Wadhawa V. Spontaneous pneumomediastinum and 
subcutaneous emphysema in patients with COVID-19. Saudi J 
Anaesth. 2021; 15(2):93-6. 

https://jcbior.com/index.php/JCBioR/article/view/123/Docx
https://pubmed.ncbi.nlm.nih.gov/32980170/
https://pubmed.ncbi.nlm.nih.gov/32980170/
https://pubmed.ncbi.nlm.nih.gov/32980170/
https://www.ctsnet.org/article/covid-19-pneumonia-associated-spontaneous-pneumomediastinum-and-pneumopericardium
https://www.ctsnet.org/article/covid-19-pneumonia-associated-spontaneous-pneumomediastinum-and-pneumopericardium
https://www.ctsnet.org/article/covid-19-pneumonia-associated-spontaneous-pneumomediastinum-and-pneumopericardium
https://www.ctsnet.org/article/covid-19-pneumonia-associated-spontaneous-pneumomediastinum-and-pneumopericardium
https://pubmed.ncbi.nlm.nih.gov/32907891/
https://pubmed.ncbi.nlm.nih.gov/32907891/
https://pubmed.ncbi.nlm.nih.gov/32907891/
https://pubmed.ncbi.nlm.nih.gov/33310838/
https://pubmed.ncbi.nlm.nih.gov/33310838/
https://pubmed.ncbi.nlm.nih.gov/33310838/
https://pubmed.ncbi.nlm.nih.gov/33310838/
https://pubmed.ncbi.nlm.nih.gov/34629677/
https://pubmed.ncbi.nlm.nih.gov/34629677/
https://pubmed.ncbi.nlm.nih.gov/34629677/
https://pubmed.ncbi.nlm.nih.gov/34629677/
https://pubmed.ncbi.nlm.nih.gov/26730086/
https://pubmed.ncbi.nlm.nih.gov/26730086/
https://pubmed.ncbi.nlm.nih.gov/26730086/
https://pubmed.ncbi.nlm.nih.gov/26730086/
https://www.scienceopen.com/document?vid=b4245d32-e83c-4a90-b1f1-fbc04fe676d9
https://www.scienceopen.com/document?vid=b4245d32-e83c-4a90-b1f1-fbc04fe676d9
https://www.scienceopen.com/document?vid=b4245d32-e83c-4a90-b1f1-fbc04fe676d9
https://pubmed.ncbi.nlm.nih.gov/12822604/
https://pubmed.ncbi.nlm.nih.gov/12822604/
https://pubmed.ncbi.nlm.nih.gov/12822604/
https://pubmed.ncbi.nlm.nih.gov/32207255/
https://pubmed.ncbi.nlm.nih.gov/32207255/
https://pubmed.ncbi.nlm.nih.gov/32207255/
https://pubmed.ncbi.nlm.nih.gov/15218989/
https://pubmed.ncbi.nlm.nih.gov/15218989/
https://pubmed.ncbi.nlm.nih.gov/15218989/
https://pubmed.ncbi.nlm.nih.gov/34188623/
https://pubmed.ncbi.nlm.nih.gov/34188623/
https://pubmed.ncbi.nlm.nih.gov/34188623/
https://pubmed.ncbi.nlm.nih.gov/34188623/


Aghajanzadeh et al. 

5 

12. Mason RJ, Slutsky A, Murray JF, Nadel JA, Gotway MB. 
Murray & Nadel's Textbook of Respiratory Medicine E-Book: 
Elsevier Health Sciences; 2015. 
13. Vancheri SG, Savietto G, Ballati F, Maggi A, Canino C, 
Bortolotto C, et al. Radiographic findings in 240 patients with 
COVID-19 pneumonia: time-dependence after the onset of 
symptoms. Eur Radiol. 2020; 30(11):6161-9. 

14. Kolani S, Houari N, Haloua M, Alaoui Lamrani Y, Boubbou M, 
Serraj M, et al. Spontaneous pneumomediastinum occurring in the 
SARS-COV-2 infection. IDCases. 2020; 21:e00806. 

 
 

https://books.google.com/books?id=Hux1BwAAQBAJ&pg=PA156-IA1&dq=Mason+RJ,+Slutsky+A,+Murray+JF,+Nadel+JA,+Gotway+MB.+Murray+%26+Nadel%27s+Textbook+of+Respiratory+Medicine+E-Book:+Elsevier+Health+Sciences;+2015&hl=en&sa=X&ved=2ahUKEwjZ0L-buaL1AhWQGBQKHZ8HCYcQ6AF6BAgEEAI#v=onepage&q=Mason%20RJ%2C%20Slutsky%20A%2C%20Murray%20JF%2C%20Nadel%20JA%2C%20Gotway%20MB.%20Murray%20%26%20Nadel's%20Textbook%20of%20Respiratory%20Medicine%20E-Book%3A%20Elsevier%20Health%20Sciences%3B%202015&f=false
https://books.google.com/books?id=Hux1BwAAQBAJ&pg=PA156-IA1&dq=Mason+RJ,+Slutsky+A,+Murray+JF,+Nadel+JA,+Gotway+MB.+Murray+%26+Nadel%27s+Textbook+of+Respiratory+Medicine+E-Book:+Elsevier+Health+Sciences;+2015&hl=en&sa=X&ved=2ahUKEwjZ0L-buaL1AhWQGBQKHZ8HCYcQ6AF6BAgEEAI#v=onepage&q=Mason%20RJ%2C%20Slutsky%20A%2C%20Murray%20JF%2C%20Nadel%20JA%2C%20Gotway%20MB.%20Murray%20%26%20Nadel's%20Textbook%20of%20Respiratory%20Medicine%20E-Book%3A%20Elsevier%20Health%20Sciences%3B%202015&f=false
https://books.google.com/books?id=Hux1BwAAQBAJ&pg=PA156-IA1&dq=Mason+RJ,+Slutsky+A,+Murray+JF,+Nadel+JA,+Gotway+MB.+Murray+%26+Nadel%27s+Textbook+of+Respiratory+Medicine+E-Book:+Elsevier+Health+Sciences;+2015&hl=en&sa=X&ved=2ahUKEwjZ0L-buaL1AhWQGBQKHZ8HCYcQ6AF6BAgEEAI#v=onepage&q=Mason%20RJ%2C%20Slutsky%20A%2C%20Murray%20JF%2C%20Nadel%20JA%2C%20Gotway%20MB.%20Murray%20%26%20Nadel's%20Textbook%20of%20Respiratory%20Medicine%20E-Book%3A%20Elsevier%20Health%20Sciences%3B%202015&f=false
https://pubmed.ncbi.nlm.nih.gov/32474630/
https://pubmed.ncbi.nlm.nih.gov/32474630/
https://pubmed.ncbi.nlm.nih.gov/32474630/
https://pubmed.ncbi.nlm.nih.gov/32474630/
https://pubmed.ncbi.nlm.nih.gov/32395425/
https://pubmed.ncbi.nlm.nih.gov/32395425/
https://pubmed.ncbi.nlm.nih.gov/32395425/