RESPIRATORY MEDICINE (1998) 92, 1269-1273

Pneumothorax in active pulmonary tuberculosis:

resurgence of an old complication?

J. BLANCO-PEREZ, J. BORDEN, L. PI~~EIRO-AMIGO, R. ROCA-SERRANO, R. IZQUIERDO

AND J. ABAL-ARCA

Service of Pulmonary Diseases,Service of Infernal Medicine and Unit of Thovacic Suugevy,

Hospifal Xeral of Vigo, Salztiago de Compostela University, Pizavro, 22, 36209 Vigo, Spain

With the recent resurgence of tuberculosis (TB) in western countries, the incidence of complicating secondary
pneumothorax has also increased. The work-up and management of this complication differs from that in other
types of secondary spontaneous pneumothorax (SSP).
Our objective was to assessclinical features and therapeutic modalities of SSPin patients with and without active
pulmonary tuberculosis (APTB). All patients diagnosed with SSP seen at the Hospital Xeral of Vigo from January
1990 to June 1995 were candidates for this study. Full clinical, radiological and microbiological examinations were
performed in all patients. Invasive procedures (thoracic catheter aspiration, thoracoscopy and thoracotomy) and
mean hospital stay were compared in patients with and without APTB.
Forty-eight patients with SSP were enrolled. Eleven patients (10 males and one female, mean age 30 i 11 years)
had APTB; and 37 patients (31 males and six females, mean age 49 f 20 years) had conditions other than APTB.
Chest pain, cough and fever were more frequent in patients with APTB (90% vs 59%; 45% vs 13.5%; 36% vs 5%,
respectively). Catheter aspiration was successfulin three of 10 (30%) of patients with APTB and in 15/23 (60.86%)
of those without APTB. Catheter aspiration time was longer in the former group (25 * 22 days vs 13 * 11 days,
P=O.17). As initial treatment, thoracoscopy was performed in seven of 37 (18.91%) of those without APTB and in
one of 10 (10%) patients with APTB. For patients with unsuccessful catheter aspiration, thoracoscopy was
performed in eight of nine (89%) patients without APTB and in none of the patients with APTB. Thoracotomy was
performed in only one of nine (11%) without APTB and in four of seven (57%) patients with APTB. Patients with
APTB had a longer hospitalization (41 vs 18 days, P<O.OOl).
We concluded that SSP and APTB was a frequent association in our study. Patients with APTB showed a lesser
and slower response to catheter aspiration. Despite severe clinical presentation and demand for more invasive
procedures, patients with APTB showed a favourable response.

RESPIR. MED. (1998) 92, 1269-1273

Introduction (SSP) is diagnosed in the presence of a pulmonary disease

(6). SSP is an important complication of respiratory TB
Resurgence of tuberculosis (TB) in western countries has that demands appropriate management. Tuberculous lung
been reported since the early 1980s mainly as a consequence cavities or blebs rupturing into the pleural space cause
of illegal drug abuse, poor living conditions and human pneumothorax. However, most of the time the mechanism
immunodeficiency virus (HIV) infection (1,2). In Spain, TB of SSP in pulmonary TB is unclear. A tuberculous
persists as a frequent disease in the general population lung cavity may open into the pleural space, leading to
(3-5). Atypical clinical presentations with both pulmonary the development of a bronchopleural fistula and a
and extrapulmonary TB have been reported, which resem- parapneumonic process (7-9).
ble those seen before the antituberculosis drug era (24). The relationship between pneumothorax and TB is flue-
Spontaneous pneumothorax (SP) occurs in the absence tuating. At the turn of this century, a 78% SSP rate was
of any blunt, penetrating trauma or barotrauma. Idiopathic reported in patients with pulmonary TB with a 50% mor-
SP is diagnosed in the absence of any underlying lung tality (9). In 1932, Kjaergaard reported the highest rate of
disease, whereas secondary spontaneous pneumothorax SP in smokers, and rupture of subpleural blebs was ident-
ified as the main mechanism for pneumothorax (10). In the
Received 23 July 1997 and accepted in revised form 16 July 1998. following decades, a lower rate of SSP associated with TB
Correspondence should be addressed to: Jose Bord&, Department was reported probably secondary to improvement in living
of Internal Medicine, Providence Hospital, 1150 Varnum St, NE, conditions and the development of antituberculous drugs
Washington, DC 20017, U.S.A. (11,12). In 1983 Getz et al. reported chronic obstructive

0954-6111/98/111269+05 $12.00/O 0 1998 W. B. SAUNDERS COMPANY LTD

1270 J. BLANCO-PEREZ ET AL.

pulmonary diseases (COPD) as the most common cause of TABLE 1. Disorders associated with SSP
SSP, followed by neoplasm, interstitial pneumonia, and TB
(13). Recently, Tanaka et al. reported pulmonary TB in No. of
patients with SSP, and TB was identified as the second Disease cases
cause of SSP after emphysema (14). To define the impact of
active pulmonary tuberculosis (APTB) in SSP, we assessed
Chronic obstructive pulmonary disease (COPD) 28
SSP in a cohort of patients with and without APTB and
Active pulmonary TB 11
compared clinical features and therapeutic modalities.
Infectious pneumonia 2
Pneumoconiosis 2
Histiocytosis X 1
Patients and Methods Pneurnocystis cavinii pneumonia 1
Lung cancer 2
We reviewed all cases of SSP diagnosed in the Xeral Cystic fibrosis 1
Hospital of Vigo from January 1990 to June 1995. Patients Total 48
with pneumothorax secondary to blunt trauma, penetrating
trauma or barotrauma were not included. APTB was
confirmed by positive Mycobacterium tuberculosis culture
from sputum, lung tissue or pleural tissue samples. If M. Tkovacotomy
tuberculosis culture was negative, the diagnosis of APTB
was supported by the presence of necrotizing granulomas Briefly, in patients who showed no response to either
from tissue samples and clinical response to antituberculous catheter drainage aspiration or lung lesion resection by
therapy. HIV testing was done in patients at high risk thoracoscopy, an open transaxillary or posterolateral
for AIDS, such as iv. drug abuser, subjects practicing thoracotomy was performed. Blebs or bullae excision,
unsafe sex or patients with a history of blood transfusion lobectomy or pleurectomy were performed according to the
according to Spanish National Consensus (15). lung abnormality, and was followed by gauze mechanical
pleural abrasion.

OPERATIVE AND NON-OPERATIVE SSP

MANAGEMENT STATISTICAL ANALYSIS

Drainage aspiuafion Results were expressed as means and SDS. The Student’s
t-test was used for comparison of use of catheter aspiration
Either pneumothorax greater than 25% of the hemithorax and duration of hospital stay variables. A P~0.05 was
or severe respiratory distress were considered indications considered significant. Statistical procedure was performed
for catheter drainage aspiration. The aspiration catheter with SPSS software for Windows V 6, IL, U.S.A.
was inserted through the second intercostal space along the
midclavicular line or through the sixth intercostal space
along the mid-axillary line. Drainage was evaluated daily Results
and pleural fluid was systematically collected for chemical
and microbiological tests and M. tuberculosis cultures. Forty-eight patients with SSP were enrolled in this study.
Eleven patients (10 males, one female, mean age 30.5 =t 11
years) had APTB, and 37 patients (31 males, six females,
Tkovacoscopy
mean age 49 * 20 years), had a condition other than APTB
A thoracoscopy was performed in SSP patients whose lungs (Table 1). A significant smoking history was present in 10
failed to re-expand after catheter drainage aspiration or in patients with APTB and in 28 without APTB. One patient
patients with recurrent SSP. General anaesthesia with in each group was a drug abuser, and the HIV test was
double-lumen endotracheal intubation was delivered to positive only in the patient without APTB. Patients with
patients in a lateral decubitus position. Heart monitoring APTB had no risk factors for SSP other than TB. For those
and pulse oximetry were done. After single lung ventilation, patients without APTB, 17 (45.9%) had history of previous
three trocars were inserted into the chest wall, one in the TB and chronic lesions were present in their upper lung
second intercostal space at the midclavicular line and the lobes on chest X-rays.
other two in the fifth intercostal space at the midaxillary A history of relapsing SSP was reported in three patients
line and posterior axillary line. All invasive procedures with APTB and in 12 patients (32%) without APTB. The
including inspection of the chest cavity and lysis of main findings of patients without APTB are listed in Table
adhesions were videotaped (Olympus, Lake Success, NY, 2. Chest pain (90%) dyspnoea (45%) cough (45%) and
U.S.A.). Parenchymal lesions were removed by an endo- fever (36%) were the most frequently reported symptoms in
scopic stapling device (Endo-GIA 30 Autosuture@ Madrid, patients with APTB on admission. The purified protein
Spain) followed by talc pleurodesis. Cultures for M. derivative (PPD, 5 units) skin test was positive in four
tuberculosis or other micro-organisms and histology were patients, and negative in another four patients. PPD result
performed on tissue samples. was not reported in three patients.
 PNEUMOTHORAX IN ACTIVE PULMONARY TB 1271

TABLE 2. Main features of patients without APTB

No. of patients %

Clinical manifestation
Dyspnoea 23 61.16
Chest pain 22 59.45
Cough and sputum 5 13.51
Fever 2 5.4
Asymptomatic 0
Chest X-ray
Unilateral/bilateral pneumothorax 36/l
Bullae 7
Tension 3
Lung scarring lesions 17
Lung interstitial lesions 3
Mean hospital stay (days) 18.95
Therapy
Expectant observation 2 5.4
Chest tube aspiration 23 61.26
Aspiration time (days) 12.88
Success on aspiration 14 6087
Thoractomy before and after chest tube aspiration 5/l
Thoracoscopy before and after chest tube aspiration 718
Bullae resection by thoracoscopy 13
Chemical pleurodesis by thoracoscopy 2
Death related to SSP 0

On presentation, unilateral SSP was seen on X-ray in APTB. A successful response to chemical pleurodesis was
all patients with APTB: three patients showed tension observed in one patient of each group.
pneumothorax with mediastinal displacement and another Combined treatment with isoniazid, rifampin and pyrazi-
three showed hydropneumothorax. Lung cavities were namide with or without ethambutol was given to six
present in four patients, three of whom had an ipsilateral patients with APTB for 6 months. Treatment for TB was
pneumothorax and one with a contralateral pneumothorax. started after the surgical procedure in all except two
Chest X-ray findings in patients without APTB are patients. One patient received a al-month treatment for TB
described in Table 2. The diagnosis of active TB was due to persistent AFB in sputum. One patient presented
supported by positive acid-fast bacilli (AFB) in sputum in with tension SSP on chest X-ray and computed tomogra-
three patients and positive culture in five. In addition, phy (CT) scan and died 8 h after admission. This patient
culture of lung tissue was positive in five and from pleural had no previous history of TB but APTB was confirmed on
tissue in four. Granuloma in lung tissue sample was autopsy.
reported in three patients, in adenopathy in two and in SSP patients with APTB were followed-up for an average
pleural tissue in one. One out of 11 patients had negative of 20.11 months. One patient developed a SSP after 12
culture and the diagnosis was based on granuloma with months of antituberculous therapy and both non-operative
AFB in the lung tissue sample. and operative treatment were required. One patient had a
The mean hospital stay was 41 * 37 days in patients with relapsing contralateral SSP after a full re-expansion of
APTB and 18 ZIZ17 days in patients without APTB the right lung. Emphysematous bullae were detected on
(P=O.Ol). Operative interventions were performed in seven surgery. A new work-up for APTB was negative in these
(63.63%) patients with APTB and of these, four were done two patients.
after catheter drainage failure (Table 3). Operative interven-
tions were performed in four patients suspected of having
persistent or recurrent idiopathic SP. In these four patients, Discussion
examination of tissue samples led to the diagnosis of
TB. Catheter drainage aspiration was required for on an In our study, APTB was the second most frequent
average of 25 ?K23 days in patients with APTB and 12 i condition associated with SSP, a condition that required
10 days in patients without APTB, (P=O.17). Chemical appropriate management and longer hospital stay. In the
pleurodesis after catheter drainage aspiration was per- present survey, 23% of our patients had APTB. Tanaka
formed in two patients with APTB and in three without et al. reported a higher rate of this association (15). This
1272 J.BLANCO-PEREZ ETAL.

TABLE 3. Treatment of SSP associated with APTB

Antituberculous
Patient drugs/months Non-operative treatment Operative treatment

1 416 Thoractomy
2 416 Thoracotomy
3 416 Thoracotomy
4 S/21 Chest tube aspiration Thoracotomy
Tetracycline pleurodesis
5 4112 Chest tube aspiration Left upper lobe resection
6 4112 Chest tube aspiration*
Tetracycline pleurodesis
I 416 Thoracotomy
8 316 Chest tube aspiration
9 416 Chest tube aspiration
10 416 Persistent chest tube aspiration Thoractomy
Persistent open thoracotomy
11-t

*Patient 6 developed a spontaneous pneumothorax.

j-Patient 11 died on admission from fulminant SSP.

difference could be related to the criteria for the diagnosis It is possible that sub-pleural blebs are the main cause of
of TB (12,15). In this study, we required definite histologi- SSP in patients with APTB. Eventually, different stages of
cal or microbiological evidence of APTB. Previous reports pulmonary TB may explain the discrepant SSP and lung
support the concept that the increased detection of SSP findings between our series and others (9).
associated with TB is related to the resurgence of TB Cultures for M tuberculosis on sputum samples con-
(1,2-4,15). In our series, 17 patients without APTB had firmed the diagnosis of TB in about half our patients. In the
history of pulmonary TB, pushing up the overall rate of remaining half of the patients of our series, positive cultures
SSP associated with TB to 58.3%. The higher rate of SSP in of lung and pleural samples were required to confirm
our patients without APTB should be interpreted with the diagnosis of TB. Therefore, a systematic search for
caution given that chronic lung sequelae may follow M. tuberculosis should be carried out in patients with SSP
lesions in both untreated and treated M. tuberculosis living in certain geographical areas or belonging to high
infection. Pulmonary TB probably contributes to SSP risk groups.
morbidity more than reported and still carries a high Longer catheter aspiration time allows both lung
social cost. re-expansion and drainage of contaminated material in
Pneumothorax in HIV-infected patients was reported patients with SSP associated with APTB (9). In our study,
most frequently in cases with Pneumocystis carinii pneu- two out of six patients with APTB had a favourable
monia (PCP) and trauma (16). Aerosolized pentamidine response to catheter aspiration. In the remaining four
treatment, a history of smoking and pneumatocele seen patients a thoracotomy was considered appropriate due to
on chest X-ray were associated with an increased risk of the presence of diffuse lung involvement. On the other
pneumothorax in HIV-infected patients (17,lS). Steroid hand, thoracoscopy was the first operative procedure in
treatment for PCP was associated with a longer require- seven (18.91%) patients without APTB. The mortality rate
ment for chest tube drainage and the presence of PCP of our patients with APTB (9%) was around half of that
showed a mortality rate twice as high as those without reported by Wilder et al. (18%) and Tanaka et al. (16%)
PCP (16,18). Unfortunately, in our series, we could not (9,15). In fact, only one of our patients with APTB
definitely show association of SSP in HIV-infected died a few hours after admission as a consequence of
patients and PCP. fulminant SSP. In contrast, none of our patients without
Pleuritic chest pain was the most common clinical feature APTB died.
in our patients with APTB followed by cough and fever, In summary, in our study, APTB was the second most
which is at slight variance with other series (9,13), in which frequent condition associated with SSP. In appropriate
TB-associated SSP were also asymptomatic. Chest pain, settings, a systematic search for M. tuberculosis in patients
cough, sputum production and fever were definitely more with SSP will lead to the correct management. Despite
frequent in our patients with APTB than in those without. severe clinical presentation, demand for more operative
Since seven of 11 (63.6%) of our patients with APTB did procedures, longer catheter aspiration time and hospital
not present with lung cavities, our series does not lend stay, patients with SSP and APTB showed favourable
support to a pathogenic link between lung cavities and SSP. response and good prognosis.
 PNEUM~THORAXINACTIVEPULMONARY TB 1273

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