Case 12749

Spontaneous pneumothorax: a
complication of tuberculosis
Published on 03.07.2015

DOI: 10.1594/EURORAD/CASE.12749
ISSN: 1563-4086
Section: Chest imaging
Area of Interest: Thorax
Procedure: Diagnostic procedure
Imaging Technique: Conventional radiography
Imaging Technique: CT
Special Focus: Infection Case Type: Clinical Cases
Authors: Elisabeth Cruces Fuentes, Ana Sánchez
González
Patient: 28 years, male

Clinical History:

A 28-year-old male Spanish patient presented with weight loss and anorexia for one year, in association with
dyspnoea, fever, cough, expectoration and left pleuritic pain during the past week. On physical examination during
chest auscultation hypophonesis was noted on the left side.
Imaging Findings:

Posteroanterior and lateral chest radiography showed a hydropneumothorax on the left side with a collapsed left
lung. On the contralateral side, ill-defined nodules and consolidations in the right upper lobe and upper segment of
the lower lobe were seen (Fig. 1). Tube thoracostomy was performed in the emergency department, with
improvement of the symptoms.
CT with intravenous contrast showed patchy areas of consolidation with air bronchogram, poorly defined margins,
predominantly in the upper lobes. I addition, centrilobular nodules and the tree-in-bud pattern was observed. On the
left side, several of these consolidations cavitated (Fig. 2). Also, CT revealed a loculated left pleural effusion with
thickened and enhanced visceral and parietal pleura (the split pleura sign), suggestive of empyema (Fig. 3). There
was no lymphadenopathy.
Discussion:

Pulmonary tuberculosis is a common worldwide lung infection.

Classically, tuberculosis is divided into primary, common in childhood, and postprimary, usually presenting in adults
[1]. The most characteristic radiological feature in primary tuberculosis is lymphadenopathy [1]. On enhanced CT,
hilar and mediastinal nodes with a central hypodense area suggest the diagnosis. Cavitation is the hallmark of
postprimary tuberculosis and appears in around half of patients [2]. Patchy, poorly defined consolidation in the apical
and posterior segments of the upper lobes, and in the superior segment of the lower lobe is also commonly
observed [1, 2].
Several complications are associated with tuberculous infection, such as haematogenous dissemination (miliary
tuberculosis) or extension to the pleura, resulting in pleural effusion [2]. Late complications of tuberculosis comprise
a heterogeneous group of processes including tuberculoma, bronchial stenosis, bronchiectasis, broncholithiasis,
aspergilloma, bronchoesophageal fistula and fibrosing mediastinitis [2].
Tuberculosis is a long-recognized and well-documented cause of secondary spontaneous pneumothorax, with an
incidence of approximately 5% in postprimary (pulmonary) tuberculosis patients, usually in severe cavitary disease.
Overall, around 1% of patients with active tuberculosis present with secondary spontaneous pneumothorax [3, 4],
nevertheless the initial presentation as spontaneous tuberculosis is exceptional.
Pleural infection results from rupture of subpleural caseous lesions, resulting in accumulation of a chronic empyema.
A bronchopleural fistula may occur spontaneously during the natural history of the disease. Both chronic empyema
and bronchopleural fistula may result in spontaneous pneumothorax, the latter with a more acute presentation [2, 3,
4].
In our case, the poorly differentiated multifocal consolidations predominately in the upper lobes, with tree-in-bud
pattern and cavitation of some of them, suggest an active post-primary tuberculosis. In addition, the patient
developed a spontaneous hydropneumothorax as a complication.
Tube thoracostomy is the indicated treatment, in conjunction with appropriate pharmacologic management of
tuberculosis and other infections [1, 2].
We conclude that secondary spontaneous pneumothorax in patients with tuberculosis occurs especially in cases
presenting a destroyed lung. It is not uncommon in the end stages of tuberculosis with a prolonged process of
cavitation, spread to new areas, and subsequent fibrosis [1, 2].
Differential Diagnosis List: Hydropneumothorax as the initial manifestation of postprimary tuberculosis., Chronic
obstructive pulmonary disease (emphysema, cystic fibrosis...), Lung cancer, Other infection (coccidioidomycosis,
aspergillosis, histoplasmosis...), Pneumocystis jiroveci (in HIV-related disease)

Final Diagnosis: Hydropneumothorax as the initial manifestation of postprimary tuberculosis.

References:

P. Van Dyck, F. M. Vanhoenacker, P. Van den Brande, A. M. De Schepper (2003) Imaging of pulmonary
tuberculosis. Eur Radiol 13: 1771-1785 (PMID: 12942281)
Kim HY, Song K, Goo JM, et al (2001) Thoracic sequelae and complications of tuberculosis. RadioGraphics 21:
839–860 (PMID: 11452057)
Surya Kant, S. Saheer, G. Hassan, and Jabeed Parengal (2011) Spontaneous resolution of massive spontaneous
tubercular pneumothorax. Case Report Pulmonol 2011:502639 (PMID: 22937428)
U Okonkwo, V Ansa, I Umoh, A Adimekwe (2013) Pulmonary tuberculosis presenting as spontaneous
pneumothorax in a young Nigerian. African Journal of Respiratory Medicine 8: 24-25
Figure 1
a

Description: Chest radiograph reveals left-sided air-fluid level (arrowhead) with pneumothorax and
consolidations in the right upper lobe and upper segment of the right lower lobe (arrow).Origin:
Department of Radiology, Hospital Morales Meseguer, Murcia, Spain
b

Description: Chest radiograph reveals left-sided air-fluid level (arrowhead) with pneumothorax and
consolidations in the right upper lobe and upper segment of the right lower lobe (arrow).Origin:
Department of Radiology, Hospital Morales Meseguer, Murcia, Spain
Figure 2
a

Description: Lung window setting reveals consolidations with cavities in the collapsed left lung (black
arrow). The right upper lobe presents multiple consolidations (white arrow). Tube thoracostomy is
positioned in the left pleural space(arrowhead). Origin: Hospital Morales Meseguer, Department of
radiology, Murcia, Spain
b

Description: Lung window setting reveals consolidations with cavities in the collapsed left lung (black
arrow). The right upper lobe presents multiple consolidations (white arrow). Tube thoracostomy is
positioned in the left pleural space (arrowhead). Origin: Hospital Morales Meseguer, Department of
radiology, Murcia, Spain
Figure 3
a

Description: Left loculated pleural effusion with thickening and enhancement of parietal and visceral
pleura (black arrow). In addition, secondary to left lung collapse (arrowhead), an ipsilateral mediastinal
shift is produced (white arrow). Origin: Hospital Morales Meseguer, Department of radiology, Murcia,
Spain
b

Description: Left loculated pleural effusion with thickening and enhancement of parietal and visceral
pleura (black arrow). In addition, secondary to left lung collapse (arrowhead), an ipsilateral mediastinal
shift is produced (white arrow). Origin: Hospital Morales Meseguer, Department of radiology, Murcia,
Spain