DOI: http://dx.doi.org/10.18203/2349-3933.ijam20212872

Ginkgo leaf sign on X-ray chest due to subcutaneous emphysema in a COVID-19 patient

Ashish Behera, Mohan Kumar H., Rohit Bakshi, Arihant Sharma

Abstract


Subcutaneous emphysema (SE) is usually encountered in cases of structural lung diseases and secondary to direct trauma or iatrogenic procedures for airway access. It is mostly associated with pneumothorax. The diagnosis is made clinically by palpation of the affected area and radiology. Here we presented a case of COVID-19 pneumonia presenting with extensive subcutaneous emphysema resulting in airway compression which was a very rare manifestation of COVID-19 infection. The COVID-19 infection led to extensive alveolar damage to the lungs and the chronic cough which may have led to this complication due to sudden change of pressure differences in the chest wall cavity. The limitation of using of personal protective equipments hindered the diagnosis of this condition as auscultation and the palpatory feelings were greatly hindered. The chest X-ray shows air in subcutaneous space and the prominence of the fibres of bilateral pectoralis muscles which gives an impression of the venous system of a Ginkgo leaf, so named as Ginkgo leaf sign. 


Keywords


Subcutaneous emphysema, Ginkgo sign, Chest X-ray, Spontaneous emphysema, COVID-19, Acute breathlessness

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References


Jones E, Gould A, Pillay TD, Khorasanee R, Sykes R, Bazo-Alvarez JC, et al. Subcutaneous emphysema, pneumomediastinum, and pneumothorax in critically ill patients with coronavirus disease 2019: a retrospective cohort study. Critic Care Explorat. 2020;2(9):0210.

Zayet S, Klopfenstein T, Mezher C, Gendrin V, Conrozier T, Abdallah YB. COVID-19 with spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema. New Microb New Infect. 2020;38:100785.

Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. Am J Roentgenol. 2009;192(3):599-612.

Kiefer MV, Feeney CM. Management of subcutaneous emphysema with "gills": case report and review of the literature. J Emerg Med. 2013;45(5):666-9.

Huang Z, Zhao S, Xu L, Chen J, Lin W, Zeng H, et al. Imaging features and mechanisms of novel coronavirus pneumonia (COVID-19): study protocol clinical trial (SPIRIT Compliant). Medicine (Baltimore). 2020;99(16):19900.

Cut TG, Tudoran C, Lazureanu VE, Marinescu AR, Dumache R, Tudoran M. Spontaneous pneumomediastinum, pneumothorax, pneumopericardium and subcutaneous emphysema-not so uncommon complications in patients with covid-19 pulmonary infection-a series of cases. J Clin Med. 2021;10(7):1346.

Alharthy A, Bakirova GH, Bakheet H, Balhamar A, Brindley PG, Alqahtani SA, et al. COVID-19 with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema in the intensive care unit: two case reports. J Infect Public Health. 2021;14(3):290-2.

Juarez-Lloclla JP, Leon-Jimenez F, Urquiaga-Calderon 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(1):86-8.