A 34-year-old man was hospitalized in Antananarivo-Madagascar for left laterothoracic pain associated with dyspnea. He reported no cigarette nor alcohol consumption, and denied any prior medical history including diabetes, hypertension, and respiratory diseases. He has no known respiratory history. There was no family history of alpha-1 antitrypsin deficiency, no notion of pneumothorax or spontaneous emphysema. He had been presenting for 10 days with headaches, diffuse arthromyalgia, and a hacking cough in a febrile context. Two days before his admission, the patient suffered from significant asthenia, followed by progressive dyspnea, chest pain aggravated by coughing and change of position.

The physical examination revealed pulsed oxygen saturation (SpO2) of 77%, polypnea of 35 cycles per minute, blood pressure of 160/80 mmHg, heart rate of 117 beats per minute, temperature of 36.7 °C, and body mass index (BMI) of 23.1 kg/m2. The patient was obnubilated, had difficulty speaking, with signs of acute respiratory distress, condensation syndrome of the entire right lung, auscultatory silence and tympany on percussion of the left lung. There was no subcutaneous snowy crepitus of the thoracic region. There was right deviation of regular heart sounds, turgidity of the jugular veins, without edema of the lower extremities or ascites.

Lab analyses made in the 2nd day of hospitalization showed a hyperleukocytosis of 27 × 103 k/µL, including 96% (25 × 103 k/µL) neutrophils, 2% (0.54 × 103 k/µL) lymphocytes, a discrete thrombocytosis of 475 × 103 k/µL, and a C-reactive protein of 75 mg/L. Renal and hepatic tests were unremarkable. D-dimer was elevated to 2571 ng/mL. The nasopharyngeal COVID-19 polymerase chain reaction (PCR) performed on the 3rd day of hospitalization was positive. Human immunodeficiency virus (HIV) serology was negative. The chest X-ray at the patient’s bed on the 2nd day of hospitalization showed an alveolar syndrome of the right lung with right deviation of the mediastinum and clarity of the right lung except at the apex (Fig. 1).

Fig. 1
figure1

Chest CT scan without contrast injection: the chest X-ray at the patient’s bed showed an alveolar syndrome of the right lung (arrow: right/up) with right deviation of the mediastinum (arrow: right/down) and clarity of the right lung except at the apex (arrow: left)

The diagnosis of COVID-19 was made, with a doubt on the complication: left emphysema or left pneumothorax. He was put on oxygen at 20 L/min through a high-flow nasal cannula connected to an oxygen cylinder; a dual antibiotic therapy with ceftriaxone slow direct intravenous 1 g daily for 10 days, associated with a roxythromycin 150 mg tablet, twice daily for 10 days; a corticotherapy with dexamethasone intravenous direct: 24 mg daily for 3 days, then 12 mg daily for 7 days, then 8 mg daily for 7 days, then 4 mg daily for 6 day. A potassium supplementation with 600 mg × 3 dose per day for 22 days; and curative doses of enoxaparin subcutaneous 0.6 ml every 12 h for 10 days. The evolution was favorable with disappearance of signs of respiratory distress, with a SpO2 of 92% under 8 L of oxygen at 14th day of hospitalization.

The thoracic scanner was done late at 15th day of hospitalization because of the dependence on oxygen therapy and the impossibility of moving the patient with a worsening of desaturation at the least movement. In addition, the radiology center is not on site, requiring a trip with an ambulance that has a capacity of 10 L of portable oxygen. The injection of contrast medium is not done because of the patient’s lack of money. The result of the CT scan is in favor of a viral pneumonia on SARS-CoV-2 with pulmonary involvement of about 95% of the parenchyma, by the presence of ground glass opacities with multilobar and multisegmental internal reticulations. Also, the presence of a voluminous left sub pleural emphysema of 22.4 cm with compression of the ipsilateral pulmonary parenchyma as well as the mediastinal structures towards the right side. At the same time, we note the presence of some pulmonary emphysema bullae on the right side (Figs. 2, 3).

Fig. 2
figure2

(Coronal and axial section): ground glass opacities with multilobar and multisegmental internal reticulations with pulmonary involvement about 95% suggestive of SARS-Cov-2 infection (arrow: right/up). Voluminous left sub pleural emphysema of 22.4 cm and some pulmonary emphysema bullae on the right (arrow: left. Fig. 3, arrow: left). Compression of the ipsilateral lung parenchyma and deviation of the mediastinal structures to the right side by a compressive phenomenon are noted

Fig. 3
figure3

(Coronal and sagittal section): ground glass opacities with multilobar and multisegmental internal reticulations with pulmonary involvement about 95% suggestive of SARS-Cov-2 infection (Fig. 2, arrow: right/up). Voluminous left sub pleural emphysema of 22.4 cm and some pulmonary emphysema bullae on the right (Fig. 2, arrow: left. arrow: left). Compression of the ipsilateral lung parenchyma and deviation of the mediastinal structures to the right side by a compressive phenomenon are noted

The diagnosis of COVID-19 pneumonia, critical form, complicated by a compressive left GE was made. Pneumothorax was ruled out by the presence of lung parenchyma at the apex and the left pulmonary base. Also, the absence of retraction of the left lung on the pulmonary hilum.

However, the tympanism of the left lung thorax and the deviation of the heart sounds persisted. On the 22nd day of hospitalization: the patient remained oxygenorequerent with SpO2 at 94% under 2 L of oxygen and desaturation at the slightest effort. A thoracic surgery was performed at 24th day of hospitalization, which confirmed the GE. The Surgery was done under general anesthesia with mechanical ventilation by a thoracotomy, then a bullectomy followed by placement of a chest tube. The chest tube was removed on day 6 of the operation. The operation was successfully performed to overcome the acute respiratory status. Nevertheless, the patient remains on long-term oxygen therapy by nasal cannula. The patient survived 2 months after his thoracic drainage, following a recurrence severe acute pneumonia.

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