Abstract Title A Rare Case of Bilateral Secondary Spontaneous Pneumothorax Due to Tuberculosis

Background A secondary spontaneous pneumothorax (SSP) is defined as a pneumothorax occurring as a complication of underlying lung disease. We describe a rare case of bilateral SSP with tuberculosis.

Case Presentation A 64-year-old male with PMH former smoker (100-pack year) and current alcohol use presented with 6-month history of progressively worsening shortness of breath and 1-month history of a productive cough with yellow sputum. He also reported dull chest pain, decreased appetite, and 10-pound weight loss. He denied fever, night sweats, hemoptysis, or sick contacts. On examination, he was afebrile, hypoxic (72% O2 saturation) and had increased respiratory effort with tripod posturing, along with bilateral wheezes and rhonchi. A chest x-ray demonstrated large bilateral pneumothorax; bilateral chest tubes were placed with lung re-expansion. A subsequent CT chest with contrast demonstrated diffuse bilateral consolidations with bilateral upper lobe cavitation; differentials included necrotizing pneumonia, malignancy, or tuberculosis. He was placed on airborne isolation and started on broad-spectrum antibiotics. The following day, AFB smear was positive for moderate acid-fast bacilli with subsequent PCR showing Mycobacterium tuberculosis (MTB). Upon further probing, he reported traveling extensively for work with multiple prolonged stays in Asia. MTB treatment was initiated with rifampin, isoniazid, pyrazinamide, and ethambutol. He was also started on clarithromycin for positive Mycobacterium avium intracellulare (MAI) infection in sputum. After four months, he was discharged (after obtaining three consecutive negative AFB samples) with instructions to complete MTB and MAI treatment.

Discussion SSP is commonly seen in patients with COPD, cystic fibrosis, malignancy, infectious/interstitial lung diseases, or connective-tissue disease. SSP complicates between 0.6% and 1.5% of cases of tuberculosis, with most cases reported from developing nations. The mean age of TB-associated SSP is 35-45 years and about 90% of patients are male. The mechanism of pneumothorax development is progressive caseating necrosis and rupture of tuberculous cavities or blebs into the pleural space. The most common presenting features of SSP are cough, dyspnea, chest pain, and fever. Chest x-ray may demonstrate cavity, consolidation or infiltration. First-line management of patients with large or symptomatic SSP is chest tube placement. Surgical repair or pleurodesis may be indicated in cases complicated by persistent air leak following chest tube placement or in cases of bronchopleural fistula. Bilateral secondary spontaneous pneumothorax due to tuberculosis is very rare and seldom reported with most of the data from developing nations. Tuberculosis should be considered in the differential diagnosis of patients presenting with secondary spontaneous pneumothorax.