{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,21]],"date-time":"2026-06-21T04:25:08Z","timestamp":1782015908300,"version":"3.54.5"},"reference-count":92,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2025,12,25]],"date-time":"2025-12-25T00:00:00Z","timestamp":1766620800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Pneumomediastinum (PM) in SARS-CoV-2 infections can have a multifaceted presentation. The most frequently described cases of spontaneous PM (SPM) occurred during the first waves of the SARS-CoV-2 pandemic due to alveolar fragility related to severe cases of interstitial pneumonia and vascular injury that predisposed to alveolar destruction and to the Macklin effect in PM development. Cases of SPM were also reported secondary to non-invasive mechanical ventilation (NIV) and to the increasing use of higher doses of corticosteroid therapy. However, true SPM in COVID-19 patients without any identifiable risk factors and presenting as a \u201cHamman syndrome\u201d (HS) has also been observed, although it represents a very rare clinical entity. Both lung dysbiosis and spike protein toxicity could be implicated in SPM, including cases occurring after COVID-19 vaccination. Furthermore, a variety of clinical entities have been reported that are similar both in COVID-19 infection and after the related COVID-19 vaccination. We present two clinical cases (a 14-year-old boy and his mother), one presenting with SPM and both showing thymic hyperplasia, myasthenic-like symptoms, and long COVID features as a post-vaccination syndrome (PACVS). This report highlights how genetic and familial predisposition could play a role in the thymic response both in COVID-19 infection and after vaccination, involving the toxicity of the spike protein as a common denominator.<\/jats:p>","DOI":"10.3390\/jcm15010159","type":"journal-article","created":{"date-parts":[[2025,12,25]],"date-time":"2025-12-25T23:52:27Z","timestamp":1766706747000},"page":"159","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Spontaneous Pneumomediastinum in COVID-19 and Myasthenic-like Symptom Complications in Two Relatives: A Coincidence or Spike Toxicity with Thymic Response in Predisposed Individuals? Two Clinical Cases with a Comprehensive Literature Review"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8037-7689","authenticated-orcid":false,"given":"Barbara","family":"Brogna","sequence":"first","affiliation":[{"name":"Unit Interventional and Emergency Radiology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Speciality, 83100 Avellino, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariagrazia","family":"Nunziata","sequence":"additional","affiliation":[{"name":"U.O.C. Internal Medicine-Moscati Hospital, 83100 Avellino, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-9804-5361","authenticated-orcid":false,"given":"Luigi","family":"Urciuoli","sequence":"additional","affiliation":[{"name":"Unit Interventional and Emergency Radiology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Speciality, 83100 Avellino, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annamaria","family":"Romano","sequence":"additional","affiliation":[{"name":"Unit of Pneumology, St. Giuseppe Moscati Hospital, 83100 Avellino, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonietta","family":"Laporta","sequence":"additional","affiliation":[{"name":"Unit Interventional and Emergency Radiology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Speciality, 83100 Avellino, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Brogna","sequence":"additional","affiliation":[{"name":"Department of Pediatric Neurology, Catholic University, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Moldovan, F., Gligor, A., Moldovan, L., and Bataga, T. 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