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.
