2 CASE HISTORY
A 60-year-old Japanese man with no medical, family, or smoking history was diagnosed with coronavirus disease 2019 (COVID-19). Two weeks later, he was bought to our hospital in an ambulance because of high fever and dyspnea. He required oxygen supplementation at 15 L/min via an oxygen mask with an oxygen reservoir and he was immediately intubated. Computed tomography (CT) revealed bilateral diffuse infiltrations (Fig.1A, 1B) and he was diagnosed as having bacterial and secondary organizing pneumonia following COVID-19 infection. He was treated with antibiotics, methylprednisolone, and heparin sodium. His respiratory condition improved gradually, and mechanical ventilation was discontinued on day 15. He complained of right chest pain on day 22, and CT revealed right-sided pneumothorax. A chest drain was inserted immediately, which was removed on day 29 after pleurodesis with minocycline (MINO) 200 mg and OK-432 5KE. However, the right-sided pneumothorax recurred on day 50, and a left-sided pneumothorax appeared on day 56. Chest drainage was performed on both sides, and an additional drain was placed on the right side (Fig. 1C). He underwent pleurodesis on both sides (right side: twice with MINO 200 mg and OK-432 5KE and twice with 100mL of autologous blood, left side: twice with 100mL of autologous blood); however, the air leak persisted. There were more leaks on the left side than on the right side; therefore, we performed a bronchial occlusion procedure using Endobronchial Watanabe Spigots®(EWS®; Novatech, La Ciotat, France) for the left-sided pneumothorax on day 68. We inserted a 6-mm EWS® into B8bⅰ and a 7-mm EWS® into B8bⅱ on the left (Fig. 1D). Bronchial occlusion procedure was performed using flexible bronchoscopes (1T290 and P290, Olympus, Tokyo, Japan) and curette (CC-4CR-1, Olympus, Tokyo, Japan). The right lung expanded fully after bronchial occlusion and pleurodesis with 100mL of autologous blood added on both sides, performed once on the right side and twice on the left side. Thereafter the air leaks on both the sides stopped, and bilateral pneumothorax improved. The right drain was removed on day 73 and the left drain on day 75. Thereafter, there was no recurrence of pneumothorax and he was discharged on day 202 after rehabilitation for ICU-acquired weakness.