AN UNUSUAL CAUSE OF SECONDARY SPONTANEOUS PNEUMOTHORAX

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Secondary spontaneous pneumothorax (SSP) is defined as a non-traumatic pneumothorax in patients with underlying lung disease. They are commonly seen in patients with conditions such as chronic obstructive pulmonary disease, cystic fibrosis, infection, and cancer. While it is widely recognized that tuberculosis (TB) can cause SSP, estimates suggest less than 1% of TB cases are complicated by SSP. This case describes a rare initial presentation of TB. CASE PRESENTATION: A 41-year-old woman from Mexico presented with acute onset sharp left-sided chest pain. She had been having pneumonia symptoms (cough, chills, sputum production) for four months and took several courses of oral antibiotics with no improvement. She had no prior episodes of pneumonia, tuberculosis or other infections, and had no sick contacts. On presentation, she was afebrile, tachycardic, tachypneic and mildly hypoxic with decreased breath sounds on the left. A chest radiograph showed a large left-sided pneumothorax, and a 14-French pigtail chest tube was placed. Computed tomography of the chest showed bronchiectasis and cystic changes with large cavitation. Sputum acid-fast bacilli staining as well as mycobacterium tuberculosis (MTB) polymerase chain reaction returned positive. She was diagnosed with secondary spontaneous pneumothorax, and RIPE therapy was initiated. The chest tube was connected to suction which produced a continuous air leak which improved when the tube was connected to water seal, raising concern for a bronchopleural fistula. The air leak persisted for 14 days, and thus she was evaluated by thoracic surgery who ultimately performed a lobectomy. DISCUSSION: This case illustrates an unusual initial presentation of tuberculosis – this patient had an SSP from underlying bronchiectasis as well as a bronchopleural fistula. Mycobacterial infections (classically, non-tuberculous mycobacterium) often complicate pre-existing bronchiectasis. MTB itself can cause bronchiectasis from longstanding tuberculous bronchitis, post-obstructive damage secondary to post-tuberculous bronchial wall stenosis, and extraluminal bronchial obstruction by enlarged tuberculous lymph nodes. This patient had no symptoms of longstanding lung disease, and a basic workup for other causes of bronchiectasis returned normal, leaving MTB as the most likely reason for her abnormal lung architecture. The acute onset SSP triggered her eventual presentation to the hospital. It is estimated that SSP complicates between 0.6% and 1.5% of cases of tuberculosis. In one series, patients with SSP from MTB were safely treated with pleural drainage for an average of 13 days (ranging from 4 - 54 days). 28% of patients required surgery for persistent air leak, as did this patient. CONCLUSIONS: SSP is a potentially fatal complication of MTB that typically responds well to pleural drainage and RIPE therapy. Surgery may be needed for continuous air leaks. REFERENCE #1: Freixinet JL, Caminero JA, Marchena J, Rodríguez PM, Casimiro JA, Hussein M. Spontaneous pneumothorax and tuberculosis: long-term follow-up. Eur Respir J. 2011;38(1):126-131. doi:10.1183/09031936.00128910 REFERENCE #2: Doucette K, Cooper R. Tuberculosis. In: Grippi MA, Elias JA, Fishman JA, Kotloff RM, Pack AI, Senior RM, Siegel MD. eds. Fishman's Pulmonary Diseases and Disorders, Fifth Edition. McGraw-Hill; Accessed April 22, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=1344§ionid=81199723 REFERENCE #3: Burguete S, DeArmond DT, Soni NJ, Peters J. Pneumothorax. In: Grippi MA, Elias JA, Fishman JA, Kotloff RM, Pack AI, Senior RM, Siegel MD. eds. Fishman's Pulmonary Diseases and Disorders, Fifth Edition. McGraw-Hill; Accessed April 29, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=1344§ionid=81193412 DISCLOSURES: No relevant relationships by Ethan Loftspring, source=Web Response No relevant relationships by Dharani Kumari Narendra, source=Web Response No relevant relationships by Divya Verma, source=Web Response