Recurrent Secondary Spontaneous Pneumothorax in Pulmonary TB- A Rare Presentation. A Case Report and Literature Review
Dr Aekta Sharma 1, Dr Kathryn Le Grice 1, Dr Ajikumar Kavidasan *1
Croydon University Hospital.
Correspondence to: Dr Ajikumar Kavidasan, Croydon University Hospital.
Copyright
© 2026 Dr Ajikumar Kavidasan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 17 July 2026
Published: 01 August 2026
DOI: https://doi.org/10.5281/zenodo.21713907
Introduction
Secondary Spontaneous Pneumothorax (SSP) is an uncommon but recognised complication of pulmonary tuberculosis (TB). Reported mechanisms include rupture of subpleural caseating cavities, development of bronchopleural fistulae, and air trapping caused by endobronchial obstruction leading to alveolar rupture (Suwa et al., 2024).
The incidence of SSP in pulmonary TB is reported in approximately 1-2% of cases, and it is most associated in those with advanced or cavitary disease (Briones-Claudett et al., 2020). Presentation of pneumothorax during the initial manifestation of undiagnosed pulmonary TB is rare and has been described predominantly in case reports and small case series (Bhanushali et al., 2025).
We report a case of recurrent secondary spontaneous pneumothorax as part of the primary presentation of pulmonary tuberculosis, highlighting the diagnostic challenges and management considerations.
Case Overview
A 24 year-old male presented to A&E with difficulty breathing and a sore throat. He had no past medical history, no recent trauma and takes no regular medication.
Upon examination, he appeared tachypnoeic, and his observations revealed a pulse rate of 136 beats per minute, a respiratory rate of 26 breaths per minute, a blood pressure of 133/76 mmHg, and a temperature of 39.2 degrees Celsius. His oxygen saturation was 94% on room air.
There was a high suspicion of pulmonary tuberculosis. Appropriate further testing was undertaken, including TB Quanti FERON, sputum acid-fast bacilli, CT chest abdomen and pelvis (Figure 1).
Following positive TB PCR sputum analysis, this patient was commenced on anti-TB treatment (ATT) regimen.
During his admission to hospital, this patient had four episodes of acute left sided pneumothorax. His pneumothoraces were slow-resolving with persistent air leak and were recurrent. Each episode of pneumothorax was managed appropriately with chest drain insertion and applying suction.
A high-resolution computed tomography (HRCT) of the thorax was performed which showed rapid progression of mid-upper zone lung fibrosis, persistent bilateral cavitating fibrosis including subpleural cavity and subpleural bullae at the left apex (figure 2).
Cardiothoracic surgeons were closely involved with this patient’s case, however . Ddue to active TB infection, he was deemed high risk for surgical intervention. Following a prolonged hospital admission, this patient completed his anti-tuberculosis treatment and has had a good clinical and radiological recovery (figure 3).
Discussion
SSP is a recognised complication of pulmonary TB (Pradana, 2020). It can occur due to the chronic inflammatory process resulting in rupture of subpleural bullae and cavities (Bhanushali et al., 2025). TB pneumothorax is more commonly associated with patients <30, with no association between characteristics such as sex or smoking status (Shamaei et al., 2011).
In this case, several conditions triggered recurrence of pneumothoraces, such as co-infection and rapidly progressive fibrosis increasing pleural fragility and impaired lung re-expansion (Pradana, 2020). This limited the effectiveness of conservative measures. As a result, SSP associated with TB is more likely to be recurrent, prolonged and refractory to standard management compared with primary spontaneous pneumothorax.
Prompt intercostal drain insertion and initiation of anti-tuberculosis treatment is vital in the management of SSP (Bhanushali et al., 2025). However, as presented in this case, prolonged air leak and recurrence is common, therefore close follow-up is crucial.
Surgical management is an important consideration for recurrent and persistent SSP, including video-assisted thoracoscopic surgery and bullectomy. However, surgery carries increased perioperative risk due to active infection and poor lung reserve with dense pleural adhesions.
Chemical pleurodesis in the form of autologous blood patch has been explored in small case series to manage persistent air leak (Martinez et al., 2024; Shaukat et al., n.d.) There have been promising case studies indicating beneficial outcomes, this may be considered for patients who are not candidates for surgical intervention (Martinez et al., 2024). Guidance on the use of this intervention is limited.
This case highlights that recurrent pneumothorax in pulmonary TB should prompt early consideration of definitive management strategies, including surgical intervention, particularly when disease progression and fibrosis are evident. A multidisciplinary approach involving respiratory medicine, thoracic surgery and infectious diseases is essential to optimise timing of surgery, ensure appropriate anti-tuberculous therapy and achieve favourable outcomes.
References