A 34-Year-Old male admitted with pulmonary tuberculosis complicated by hydropneumothorax and mediastinal emphysema

Birsen Pinar Yildiz; Arzu Deniz Aksan; Merve Sari Akyüz; Gönenç Ortaköylü

doi:10.4103/ijmy.ijmy_130_20

CASE REPORT

Year : 2022 | Volume : 11 | Issue : 2 | Page : 199-201

A 34-Year-Old male admitted with pulmonary tuberculosis complicated by hydropneumothorax and mediastinal emphysema

Birsen Pinar Yildiz, Arzu Deniz Aksan, Merve Sari Akyüz, Gönenç Ortaköylü
Department of Pulmonology, University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey

Date of Submission	23-Jul-2020
Date of Decision	31-Aug-2020
Date of Acceptance	15-May-2022
Date of Web Publication	14-Jun-2022
Date of Print Publicaton	14-Jun-2022

Correspondence Address:
Birsen Pinar Yildiz
University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Istanbul
Turkey

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijmy.ijmy_130_20

Abstract

Spontaneous hydropneumothorax (HP) and mediastinal emphysema (ME) are infrequently presented complications of pulmonary tuberculosis (TB). A-34-year-old Pakistani male presented with dyspnea, productive cough, and right-sided pleuritic chest pain. He had no history of any surgery, TB, comorbid disease, or other serious pulmonary diseases. Chest radiography revealed a right-sided HP and parenchymal infiltration. The laboratory results of pleural effusion showed elevated adenosine deaminase levels with the empyema features. Acid-fast bacilli were detected and Mycobacterium tuberculosis without any drug resistance grew in the culture both in the sputum and pleural fluid. A chest tube was inserted immediately. A prolonged airway leak was detected. Hepatotoxicity protocol has been initialized (due to increased hepatic enzymes in the initial presentation) and followed without observing any complications associated with the treatment. On the 25^th day of the standard TB treatment protocol, we observed hepatic enzymes in the normal range. Around 40-days of a hospitalization period, he started developing fever and methicillin-resistant Staphylococcus aureus was detected in the pleural fluid culture. We introduced linezolid to the treatment regimen in addition to the antituberculosis protocol. Although spontaneous ME is a benign disease, it might be life-threatening and difficult to manage when complicated with HP and active TB infection. Active TB should be considered a differential diagnosis once ME or HP was detected, and treatment should be started immediately for both diseases.

Keywords: Chest tube, hydropneumothorax, mediastinal emphysema, tuberculosis

How to cite this article:
Yildiz BP, Aksan AD, Akyüz MS, Ortaköylü G. A 34-Year-Old male admitted with pulmonary tuberculosis complicated by hydropneumothorax and mediastinal emphysema. Int J Mycobacteriol 2022;11:199-201

How to cite this URL:
Yildiz BP, Aksan AD, Akyüz MS, Ortaköylü G. A 34-Year-Old male admitted with pulmonary tuberculosis complicated by hydropneumothorax and mediastinal emphysema. Int J Mycobacteriol [serial online] 2022 [cited 2022 Jul 6];11:199-201. Available from: https://www.ijmyco.org/text.asp?2022/11/2/199/347529

Introduction

Hydropneumothorax (HP) and mediastinal emphysema (ME) are rarely seen complications in the course of tuberculosis (TB) infection. It needs careful management and emergent treatment due to potential morbidity and life-threatening risk. Intercostal drainage (ICD) tube insertion and careful clinical management would be critical for saving patients' life.

ME otherwise known as pneumomediastinum (PM) can be expressed as the presence of free air in the mediastinum which is another rare complication of TB. Spontaneous PM is reported rarely.^[1],[2] Although benign and self-limiting disorder, it would be difficult to manage which was seen together with active TB infection and HP as presented in our case.

Case Report

A 34-year-old Pakistani male presented with dyspnea, productive cough, and right-sided pleuritic pain. He reported fever, chills intermittently, and 14-pound weight loss over the preceding 3 weeks. Vital signs were as follows: temperature of 36.5°C; respiratory rate of 28 breaths/min; and oxygen saturation of 93% on room air. The patient's physical examination was remarkable for diminished right-sided lung sounds without any organomegaly or peripheral lymphadenopathy.

Chest radiography has been revealed a right-sided HP and parenchymal infiltration. A right-sided 28 F chest tube was placed in the emergency department. A chest computed tomography (CT) scan showed a cavitary lesion in the right upper lobe adjacent to the subcutaneous emphysema, ME, and pleural effusion on the right side [Figure 1] and [Figure 2]. Widespread consolidation and secondary collapsed areas to the effusion were observed in the middle and lower lobes of the right lung. According to radiological features and a person who comes from endemic areas for TB, there was high suspicion for TB. Since the purulent pleural fluid has been collected, empyema was considered. Acid-fast bacilli (AFB) were detected and Mycobacterium tuberculosis was revealed in the sputum and pleural effusion culture without any drug resistance. He has high liver function test (aspartate aminotransferase 143; alanine aminotransferase 239). We started TB treatment as a hepatotoxicity regimen (streptomycin [S 1000 mg], moxifloxacin [MFX 400 mg], cycloserine [CS 750 mg], and ethambutol [EMB 1000 mg]) according to national TB guidelines. ICD catheter was taken with negative suction and 2 weeks later, the ME was regressed. When hepatic enzymes were detected between normal range on the 25^th day, we started isoniazid (INH 300), rifampicin (RIF 600 mg), and pyrazinamide (PZA 1500 mg) step treatment, stopped cycloserine and moxifloxacin. 40^th day of the hospitalizations, he has a fever and methicillin-resistant Staphylococcus aureus was detected in the culture of the pleural fluid. Linezolid added in medical treatment.

Figure 1: Chest radiography on the 1^st day of admission shows right-sided hydropneumothorax

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Figure 2: Computed tomography images revealed right-sided hydropneumothorax with the features of mediastinal emphysema and subcutaneous emphysema

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Discussion

In the study reviewed 57 patients having HP, TB was the most common etiology with 80.7% of the patients. Intercostal chest tube drainage was required for long duration (median 24.8 ± 13.1 days) time.^[3] Although AFB smear was not detected positive in the majority of the pleural effusion, our patient has a positive result in the effusion. It was reported smear-positive results in the pleural fluid as 14% by Kasargod and Awad.^[3] Particularly in a country with a high prevalence of TB, it should be considered a cause of HP. Thus, AFB smear of effusion or culture positivity for M. tuberculosis would be diagnostic. Either rupture of cavity or TB focus would be a reason for pneumothorax or HP.

The pleural fluid analysis revealed exudative effusions with the lymphocyte predominance and elevated adenosine deaminase (ADA) levels which confirmed the results of previous studies^[3],[4] Although ADA levels have a high accuracy of the diagnosis for pleural TB, different results have been reported in previous studies. It is possible that heterogeneity of the data would be associated with the population have chosen or TB prevalence of the country in which data obtained. Thus, it is important to know the accuracy results for own country which we previously reported that the positive predictive value is 98.8% with the >55 U/L of ADA and age <50 combined.^[5]

ICD tube was inserted to the treatment of HP in our case as similar to the previous reports.^[6] Kasargod and Awad pointed requirements of the long duration of treatment and chest tube insertion for HP.^[3] It was reported a higher median length of stay in patients with PM concomitant pneumothorax compared to patients without pneumothorax.^[7],[8] We confirmed the previous results and expect even much longer duration of treatment in our case due to HP and PM which complicates the clinical course together.

After the air reaches to the mediastinum, it can be extended areas which resulting in subcutaneous emphysema. We detected subcutaneous emphysema after the admission and spontaneously resolved on the 15^th day after chest tube insertion.

Spontaneous ME has been revealed in our case concomitant to the HP and acute parenchymal TB infiltration. In the retrospectively analyzed 13 spontaneous PM patients, six were reported concomitant with the pneumothorax while TB sequelae in five and active pulmonary TB in only one case. They also report that 85% of the patients developed subcutaneous emphysema during the hospitalizations which we evaluated the same course in our case.^[7] Various precipitating factors could be responsible for the development of spontaneous PM, which might be excessive or intractable cough in our case due to active TB. The spontaneous PM has been described mostly in young males such as our patients.^[9] Chest pain and dyspnea are frequently reported symptoms in the previous data which we confirmed the same result.^[7],[10] Unlike previous reports addressed, the air leak is small in spontaneous PM, our case has prolonged duration of air leak probably associated with underlined active TB infection and concomitant HP. Although previous TB infection and sequelae are increasing the risk of spontaneous PM, active TB infection could have a potential risk despite limited data.^[11] We confirmed that active TB infection might have a potential risk for spontaneous PM.

The diagnostic role of CT for spontaneous PM over chest radiograph is controversial in the literature. We believe that CT gives a more comprehensive approach for this case as either evaluate preexisting lung disorders complicate and adversely affect PM course or deny an insufficient diagnosis of PM with the concomitant diseases to chest radiograph evaluated normally.

Acknowledgments

We would like to thank nurse of unit manager Mürvet Sakallı and all other nurses for convenient assistance of caring for the patients and support for the data acquisition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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