J Respir Indo Vol. 43 No. 2 April 2023 101 Late-Onset Pneumothorax and Bullous Disease in Post-COVID-19 Pneumonia with Severe ARDS Ira Nurrasyidah 1 , Vincentius Adrian Madargerong 1 , Desi Rahmawaty 2 1 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Lambung Mangkurat, RSUD Ulin, Banjarmasin, Indonesia 2 Faculty of Medicine, Universitas Lambung Mangkurat, Banjarmasin, Indonesia Abstract Background: Patients with COVID-19 pneumonia may develop bullae that can rupture into spontaneous pneumothorax (SP) during the diagnosis and treatment, which can be a predictor of a poor prognosis. However, late-onset bullous disease and SP after recovering from COVID-19 are unusual. Case: A 48-year-old male presented with sudden shortness of breath accompanied by chest pain. Three weeks earlier, the patient had finished treatment in the COVID-19 isolation room for 20 days with a diagnosis of COVID-19 pneumonia with severe ARDS. Physical examination demonstrates tachypnea, desaturation, decreased vesicular breath sounds, and hyperresonance percussion on the right hemithorax; without rhonchi or wheezing. Chest X-ray and CT scan showed a right pneumothorax with infected subpleural giant bullae in right perihilar, right lung collapse, minimal right- to-left lung herniation and post-covid pulmonary fibrosis. Culture and sensitivity examination of the pleural fluid showed the growth of Providencia stuartile. A chest tube was placed for the management of the pneumothorax. Subsequently, according to the results of culture and antibiotic sensitivity test, the patient was treated using piperacilin/tazobactam and amikacin. The patient showed clinical and radiological improvement following 41 days of treatment and could be managed as an outpatient. Conclusion: Our patient had infected giant bullae and pneumothorax post COVID-19 pneumonia and severe ARDS. The patient did not undergo a bullectomy in consideration of the post-COVID-19 condition and was managed conservatively using adequate chest tube and antibiotics. Patient responded well to therapy, showed clinical improvement and could be discharged. Keywords: ARDS, COVID-19, late-onset, pneumothorax, pulmonary bullous disease Corresponding Author: Ira Nurrasyidah | Department of Pulmonology and Respiratory medicine, Faculty of Medicine, Universitas Lambung Mangkurat, RSUD Ulin, Banjarmasin, Indonesia | ira.nurrasyidah@ulm.ac.id Submitted: June 30 th , 2022 Accepted: January 19 th , 2023 Published: April 28 th , 2023 J Respirol Indones. 2023 Vol. 43 No. 2: 101–5 https://doi.org/10.36497/jri.v43i2.354 Creative Commons Attribution- NonCommercial 4.0 International License INTRODUCTION During the diagnosis and treatment of COVID- 19 pneumonia, patients may have a number of complications. Complications arise as a result of cell damage, a strong innate immune response with the release of inflammatory cytokines, and the pro- coagulant condition induced by SARS-CoV-2 infection. 1,2 Fibrosis and pulmonary bullae are two COVID- 19 problems that might occur. In the instance of COVID-19 pneumonia, ground glass opacity (GGO) and consolidation findings occurred early on the CT scan, increased in quantity and density, and were eventually absorbed, leaving fibrous alterations in their original site. Pulmonary bullae are air-filled pockets in the lung that develop as a result of emphysematous deterioration of the lung parenchyma. 3 Bullae development is caused by inflammatory injury to the bronchioles, which results in air entrapment. Bullae may form as a result of mechanical forces interacting with weakened tissue. 3 Pulmonary bulla can rupture into spontaneous pneumothorax (SP), which can indicate a poor prognosis. 4 There has been no specific report on the prevalence of SP in COVID-19 to date. Several prior studies reported SP during diagnosis and therapy of COVID-19. 3,5–7 Although SP due to pulmonary bullae rupture is relatively common in COVID-19 patients, however, late-onset bullous disease and SP after recovering from COVID-19 are unusual. In order to improve clinicians' understanding and treatment of the disease, we summarized the clinical characteristics of our patient with late-onset bullous disease and SP after recovering from COVID-19. Case Report