Spontaneous Pneumo-Mediastinum in a Post-COVID-19 Patient with Systemic Sclerosis

Pulmonary involvement is the most common cause of death among patients with systemic sclerosis (SSc). The current coronavirus disease 2019 (COVID-19) is particularly problematic to manage in SSc patients since they may experience a more severe evolution of COVID-19 due to the pre-existent interstitial lung disease (ILD) and the administration of immunosuppressive treatments. In addition, the remarkable radiological similarities between SSc-ILD and COVID-19 complicate the differential diagnosis between these two entities. Herein, we present the first case of spontaneous pneumo-mediastinum in a post-COVID-19 patient with SSc. In our patient, both smoking and pulmonary fibrosis could lead to cyst formation, which possibly spontaneously broke and caused pneumo-mediastinum. Moreover, megaesophagus perforation due to the smooth muscle atrophy, replacement with fibrosis, and achalasia may extend into the mediastinum or pleural space and has also been described as a rare case of spontaneous pneumo-pericardium. Finally, spontaneous pneumo-mediastinum and pneumothorax have been recently reported as an established complication of severe COVID-19 pneumonia and among COVID-19 long-term complication. This case report underlines that the worsening of respiratory symptoms in SSc patients, especially when recovered from COVID-19, requires further investigations for ruling out other tentative diagnoses besides the evolution of the SSc-ILD.

Automated summary

Pulmonary involvement is the leading cause of death in patients with systemic sclerosis (SSc). COVID-19 poses a particular challenge in managing SSc patients as they may experience a more severe progression of the disease due to pre-existing interstitial lung disease (ILD) and immunosuppressive treatments. Furthermore, the radiological similarities between SSc-ILD and COVID-19 complicate the differential diagnosis. This case report presents the first instance of spontaneous pneumo-mediastinum in a post-COVID-19 SSc patient. The report underscores the importance of investigating respiratory symptom exacerbation in SSc patients, especially those who have recovered from COVID-19, to rule out other potential diagnoses.