Peer-review started: March 17, 2021
First decision: March 31, 2021
Revised: April 14, 2021
Accepted: July 9, 2021
Article in press: July 9, 2021
Published online: August 8, 2021
The incidence of secondary coinfections particularly fungal infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not well described. Little is known of the complications that could be encountered in such conditions.
A 50-year-old Hispanic male who was a prior smoker presented with shortness of breath. He was diagnosed with SARS-CoV-2. He improved and was discharged with home oxygen. A month later, he presented with sudden onset cough and shortness of breath. Chest X-ray showed development of right-sided tension pneumothorax, right pleural effusion and an air-filled cystic structure. Computed tomography thorax showed findings suggestive of pulmonary coccidioidomycosis. Coccidioides antigen was positive, and fluconazole was initiated. For pneumothorax, a pigtail catheter was placed. The pigtail chest tube was later switched to water seal, unfortunately, the pneumothorax re-expanded. Another attempt to transition chest tube to water seal was unsuccessful. Pigtail chest tube was then swapped to 32-Fr chest tube and chemical pleurodesis was performed. This was later transitioned successfully to water seal and finally removed. He was discharged on a four-week oral course of fluconazole 400 mg and was to follow up closely as an outpatient for continued monitoring.
Pneumothorax is associated with a worse prognosis, especially with comorbidities such as diabetes, immunosuppression and malignancy. Suspicion for concomitant fungal infection in such patients should be high and would necessitate further investigation.
Core Tip: This case highlights the presence of a concomitant infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coccidioidomycosis. This was further complicated by the formation of a refractory pneumothorax. Fungal infections in SARS-CoV-2 patients appear underdiagnosed and may have an increased prevalence in patients with comorbidities, such as malignancies, diabetes, and chronic lung disorders. Total 39 case reports were included in our literature review. The risk of pneumothorax and pneumomediastinum formation does not necessarily increase from a history of smoking or underlying lung pathology; however, the incidence of a prolonged cough prior to pneumothorax formation seems to be consistent across several reported cases.