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Pneumothorax and pneumomediastinum complicating acute miliary tuberculosis
Tubercle 58 (1977) 79-82
PNEUMOTHORAX
AND
PNEU#OMEDIASTINUM MILIARY TUBERCULOSIS
COMPLICATING
ACUTE
R. K. Narang, Surendra Kumar and Ashok Gupta Department
of Tuberculosis and Chest Diseases, G.S. V.M. Medical
College, Kanpur, India
Summary Five adult cases of acute miliary tuberculosis are described. Four were complicated by pneumothoraces and 1 by pneumomediastinum. In 2 cases pneumothorax occurred on the left side while in 2 it was bilateral. None of the 5 patients died. R&urn6 Description de 5 cas de tuberculose miliaire aigue de I’adulte. Quatre de ces cas dtaient compliques de pneumothorax et un de pneumomediastin. Dans 2 cas, le pneumothorax s’est produit B gauche et dans les 2 autres, il a 6te bilateral. Aucun de ces 5 malades n’est d&cede. Resumen Se describen 5 cases de tuberculosis miliar aguda en adultos. Cuatro cases se complicaron con neumotdrax y uno, con neumoperitoneo. El neumotorax fue bilateral en dos cases, y en 10s otros dos fue izquierdo. No fallecid ningun paciente. Introduction Pneumothorax is a well known complication of cavitary tuberculosis. However it is extremely rare in acute miliary tuberculosis and only 8 cases have been reported in the world (Peiken, Lamberta and Seriff, 1974). Pneumomediastinum is another uncommon complication of this disease, which has prompted us to report the following 5 cases. Case histories Case 7 A 27 year old Hindu housewife was admitted to hospital on 9 December 1969 complaining of cough, fever and anorexia for 3 months. Sputum smear was negative for acid-fast bacilli, Mantoux test (1TU of PPD RT23) was positive (induration 20 mm) and an x-ray of the chest showed bilateral miliary shadows. She was treated with streptomycin 0.75 g and isoniazid 300 mg daily. On the tenth day after admission she developed a small pneumothorax on the left side. The lung expanded with needle aspiration of the pleural space. She was discharged after 2 months in hospital with advice to continue treatment with isoniazid and thiacetazone. She was readmitted on 21 April 1970 complaining of pain on the right side of the chest. An x-ray of the chest showed a small right pneumothorax with bilateral miliary shadows. Needle aspiration of the pneumothorax caused the lung to re-expand. Liver biopsy with a Vim Silverman needle was done to confirm the diagnosis. A histopathological examination of the tissue showed focal areas of necrosis with tubercles, epithelioid cells and giant cells. The patient was retreated with streptomycin and isoniazid. Case 2 A 20 year old Muslim female was admitted to hospital on 20 April 1972 complaining of cough and fever for 3 months. Twenty days before admission she had had sudden severe
80
Narang and others
pain on the left side of the chest and became breathless. Clinical examination revealed a very dyspnoeic, ill-looking patient. There were signs of a pneumothorax on the left side and there was also bilateral cervical adenopathy. Mantoux test (PPD RT23) was positive (induration 16 mm), Hb was 8 g/dl and there was a mild leucocytosis. A chest x-ray confirmed a large pneumothorax with collapse of three-quarters of the left lung. The right lung showed miliary mottling. Air aspiration by intubation connected to an under-water seal was done and treatment begun with streptomycin 0.75 g, isoniazid 300 mg and prednisolone 20 mg daily. The patient improved rapidly when the lung left had partly re-expanded. The lung expanded completely after about a month. The patient was followed up for 2 years and she remained well with no recurrence of pneumothorax. The diagnosis of tuberculosis
in this case was confirmed by biopsy of a cervical lymph node.
Case 3 A 32 year old Hindu male had cough and fever for 4 months’before admission to hospital on 7 September 1972. A chest x-ray taken on 15 August had shown bilateral coarse miliary shadows confluent in some areas. A Mantoux test (PPD RT23) was positive (induration 20 mm) ; a sputum smear was positive. There was a mild leucocytosis. The patient was put on streptomycin 0.75 g and isoniazid 300 mg daily. On 27 October he complained of severe pain on the left side of the chest with breathlessness. An x-ray of the chest showed a pneumothorax with partial collapse of the left lung. After needle aspiration the lung expanded in 2 weeks. The patient was discharged on 15 November when he was asymptomatic and the sputum smear was negative. Case 4 A 21 year old Hindu male complained of high fever and cough for four months and an x-ray of the chest taken on 12 May 1976 showed bilateral miliary shadows. Treatment with streptomycin and isoniazid was started by a general practitioner. On 10 June 1976 the patient complained of severe pain on the left side of the chest with breathlessness and was referred to hospital. Clinical examination revealed signs of a pneumothorax on the left side and an x-ray of the chest confirmed the diagnosis. The collapsed lung expanded in 10 days after insertion of an intercostal rubber catheter connected to an underwater seal. Mantoux test (PPD RT23) was positive (induration 10 mm) and culture of the sputum on Ldwenstein-Jensen medium showed Mycobacterium tuberculosis. Treatment with streptomycin 0.75 g, isoniazid 300 mg and PAS 10 g daily was started. On 7 August the patient again became breathless. A chest x-ray revealed bilateral pneumothoraces, although very little air was present on the right side. Needle aspiration of the left side was done which relieved the patient’s dyspnoea. A week later he became very dyspnoeic again and an x-ray of his chest showed almost complete collapse of the left lung and the pneumothorax on the right side had also become larger. He was treated with intubation of the left side and needle aspiration of the right side. This resulted in complete expansion of the right lung although a small air pocket remained on the left side. The patient was discharged from hospital on 22 September with advice to continue antituberculosis drugs. Case 5 A 25 year old Hindu housewife was admitted to hospital on 22 April 1968 with complaints of cough and fever for 2 months. On clinical examination fine crepitations were heard on both
Pneumothorax
Figure 1
in miliary tuberculosis
81
Case 5: X-ray of the chest showing bilateral mottling in the lung fields and pneumomediastinum.
sides of the chest. Sputum smear was negative but culture from a laryngeal M. tubercolosis. A chest x-ray showed bilateral miliary shadows.
swab grew
The patient was treated with streptomycin 0.75 g, isoniazid 300 mg and prednisolone 20 mg daily. Two days after admission she became a little breathless and was found to have subcutaneous emphysema in the neck although Hamman’s sign was negative. A chest x-ray (Figure 1) showed a pneumomediastinum. There was no pneumothorax. No special treatment was given for this complication and a chest x-ray taken on 1 June showed complete absorption of air from the mediastinum and subcutaneous tissues. The patient was discharged on 8 June with advice to continue antituberculosis drugs. She was followed up for 2 years after discharge and remained well. Discussion Peiken, Lamberta and Seriff (1974) reported a case of acute miliary tuberculosis complicated by bilateral pneumothoraces. They reviewed the world literature and found only 7 other cases of this complication and the pneumothorax was bilateral in only two of them. In the present report 4 cases of acute miliary tuberculosis complicated by pneumothorax are described. The pneumothorax was on the left side in 2 while in the remaining 2 it was bilateral, first occurring on the left side and then on the right. Two patients were men and 2 women, age range 20-32 years. The fifth case in our series was a case of acute miliary tuberculosis complicated by pneumomediastinum without pneumothorax. We have included this case because of the rarity of this complication
82
Narang and others
The pathogenesis of pneumothorax in cavitary tuberculosis is readily explained by rupture of the cavity through the visceral pleura. The mechanism in acute miliary tuberculosis is, however, not clear and there are several possibilities. One mechanism as suggested by Peiken, Lamberta and Seriff (1974) might be an initial pneumomediastinum with leakage of air through the mediastinal pleura causing bilateral pneumothorax. In the world literature reviewed by Peikin and others only 15 cases of mediastinal emphysema complicating acute miliary tuberculosis have been reported. In none of these, however, was pneumothorax present and in the present series the patient with a pneumomediastinum did not have a pneumothorax. We have reported another case of acute miliary tuberculosis with pneumomediastinum in a seven year old child (Narang and Mital, 1967) and this is included in Peikin’s review. In 2 of our cases the pneumothorax was bilateral but there was no evidence of pneumomediastinum and pneumomediastinum was not present in the 3 cases of bilateral pneumothorax reported in the literature. Thus from this experience pneumomediastinum and interstitial emphysema does not seem to be a likely cause of pneumothorax in acute miliary tuberculosis. Another possible mechanism might be caseation or necrosis of subpleural miliary nodules and their subsequent rupture through the pleura. Alternatively bullous lesions might form near miliary tubercles which rupture to produce a pneumothorax. Either one or both of these mechanisms may be operative in acute miliary tuberculosis complicated by pneumothorax. References Narang, R. K., Et Mital, 0. P. (1967). Interstitial and mediastinal emphysema complicating acute miliary tuberculosis. Indian Journal of Chest Diseases, 9, 58. Peiken, A. S., Lamberta, F., 8 Seriff, N. S. (1974). Bilateral recurrent pneumothoraces. A rare complication of miliary tuberculosis. American Review of Respiratory Diseases, 110, 512.
PNEUMOTHORAX
AND
PNEU#OMEDIASTINUM MILIARY TUBERCULOSIS
COMPLICATING
ACUTE
R. K. Narang, Surendra Kumar and Ashok Gupta Department
of Tuberculosis and Chest Diseases, G.S. V.M. Medical
College, Kanpur, India
Summary Five adult cases of acute miliary tuberculosis are described. Four were complicated by pneumothoraces and 1 by pneumomediastinum. In 2 cases pneumothorax occurred on the left side while in 2 it was bilateral. None of the 5 patients died. R&urn6 Description de 5 cas de tuberculose miliaire aigue de I’adulte. Quatre de ces cas dtaient compliques de pneumothorax et un de pneumomediastin. Dans 2 cas, le pneumothorax s’est produit B gauche et dans les 2 autres, il a 6te bilateral. Aucun de ces 5 malades n’est d&cede. Resumen Se describen 5 cases de tuberculosis miliar aguda en adultos. Cuatro cases se complicaron con neumotdrax y uno, con neumoperitoneo. El neumotorax fue bilateral en dos cases, y en 10s otros dos fue izquierdo. No fallecid ningun paciente. Introduction Pneumothorax is a well known complication of cavitary tuberculosis. However it is extremely rare in acute miliary tuberculosis and only 8 cases have been reported in the world (Peiken, Lamberta and Seriff, 1974). Pneumomediastinum is another uncommon complication of this disease, which has prompted us to report the following 5 cases. Case histories Case 7 A 27 year old Hindu housewife was admitted to hospital on 9 December 1969 complaining of cough, fever and anorexia for 3 months. Sputum smear was negative for acid-fast bacilli, Mantoux test (1TU of PPD RT23) was positive (induration 20 mm) and an x-ray of the chest showed bilateral miliary shadows. She was treated with streptomycin 0.75 g and isoniazid 300 mg daily. On the tenth day after admission she developed a small pneumothorax on the left side. The lung expanded with needle aspiration of the pleural space. She was discharged after 2 months in hospital with advice to continue treatment with isoniazid and thiacetazone. She was readmitted on 21 April 1970 complaining of pain on the right side of the chest. An x-ray of the chest showed a small right pneumothorax with bilateral miliary shadows. Needle aspiration of the pneumothorax caused the lung to re-expand. Liver biopsy with a Vim Silverman needle was done to confirm the diagnosis. A histopathological examination of the tissue showed focal areas of necrosis with tubercles, epithelioid cells and giant cells. The patient was retreated with streptomycin and isoniazid. Case 2 A 20 year old Muslim female was admitted to hospital on 20 April 1972 complaining of cough and fever for 3 months. Twenty days before admission she had had sudden severe
80
Narang and others
pain on the left side of the chest and became breathless. Clinical examination revealed a very dyspnoeic, ill-looking patient. There were signs of a pneumothorax on the left side and there was also bilateral cervical adenopathy. Mantoux test (PPD RT23) was positive (induration 16 mm), Hb was 8 g/dl and there was a mild leucocytosis. A chest x-ray confirmed a large pneumothorax with collapse of three-quarters of the left lung. The right lung showed miliary mottling. Air aspiration by intubation connected to an under-water seal was done and treatment begun with streptomycin 0.75 g, isoniazid 300 mg and prednisolone 20 mg daily. The patient improved rapidly when the lung left had partly re-expanded. The lung expanded completely after about a month. The patient was followed up for 2 years and she remained well with no recurrence of pneumothorax. The diagnosis of tuberculosis
in this case was confirmed by biopsy of a cervical lymph node.
Case 3 A 32 year old Hindu male had cough and fever for 4 months’before admission to hospital on 7 September 1972. A chest x-ray taken on 15 August had shown bilateral coarse miliary shadows confluent in some areas. A Mantoux test (PPD RT23) was positive (induration 20 mm) ; a sputum smear was positive. There was a mild leucocytosis. The patient was put on streptomycin 0.75 g and isoniazid 300 mg daily. On 27 October he complained of severe pain on the left side of the chest with breathlessness. An x-ray of the chest showed a pneumothorax with partial collapse of the left lung. After needle aspiration the lung expanded in 2 weeks. The patient was discharged on 15 November when he was asymptomatic and the sputum smear was negative. Case 4 A 21 year old Hindu male complained of high fever and cough for four months and an x-ray of the chest taken on 12 May 1976 showed bilateral miliary shadows. Treatment with streptomycin and isoniazid was started by a general practitioner. On 10 June 1976 the patient complained of severe pain on the left side of the chest with breathlessness and was referred to hospital. Clinical examination revealed signs of a pneumothorax on the left side and an x-ray of the chest confirmed the diagnosis. The collapsed lung expanded in 10 days after insertion of an intercostal rubber catheter connected to an underwater seal. Mantoux test (PPD RT23) was positive (induration 10 mm) and culture of the sputum on Ldwenstein-Jensen medium showed Mycobacterium tuberculosis. Treatment with streptomycin 0.75 g, isoniazid 300 mg and PAS 10 g daily was started. On 7 August the patient again became breathless. A chest x-ray revealed bilateral pneumothoraces, although very little air was present on the right side. Needle aspiration of the left side was done which relieved the patient’s dyspnoea. A week later he became very dyspnoeic again and an x-ray of his chest showed almost complete collapse of the left lung and the pneumothorax on the right side had also become larger. He was treated with intubation of the left side and needle aspiration of the right side. This resulted in complete expansion of the right lung although a small air pocket remained on the left side. The patient was discharged from hospital on 22 September with advice to continue antituberculosis drugs. Case 5 A 25 year old Hindu housewife was admitted to hospital on 22 April 1968 with complaints of cough and fever for 2 months. On clinical examination fine crepitations were heard on both
Pneumothorax
Figure 1
in miliary tuberculosis
81
Case 5: X-ray of the chest showing bilateral mottling in the lung fields and pneumomediastinum.
sides of the chest. Sputum smear was negative but culture from a laryngeal M. tubercolosis. A chest x-ray showed bilateral miliary shadows.
swab grew
The patient was treated with streptomycin 0.75 g, isoniazid 300 mg and prednisolone 20 mg daily. Two days after admission she became a little breathless and was found to have subcutaneous emphysema in the neck although Hamman’s sign was negative. A chest x-ray (Figure 1) showed a pneumomediastinum. There was no pneumothorax. No special treatment was given for this complication and a chest x-ray taken on 1 June showed complete absorption of air from the mediastinum and subcutaneous tissues. The patient was discharged on 8 June with advice to continue antituberculosis drugs. She was followed up for 2 years after discharge and remained well. Discussion Peiken, Lamberta and Seriff (1974) reported a case of acute miliary tuberculosis complicated by bilateral pneumothoraces. They reviewed the world literature and found only 7 other cases of this complication and the pneumothorax was bilateral in only two of them. In the present report 4 cases of acute miliary tuberculosis complicated by pneumothorax are described. The pneumothorax was on the left side in 2 while in the remaining 2 it was bilateral, first occurring on the left side and then on the right. Two patients were men and 2 women, age range 20-32 years. The fifth case in our series was a case of acute miliary tuberculosis complicated by pneumomediastinum without pneumothorax. We have included this case because of the rarity of this complication
82
Narang and others
The pathogenesis of pneumothorax in cavitary tuberculosis is readily explained by rupture of the cavity through the visceral pleura. The mechanism in acute miliary tuberculosis is, however, not clear and there are several possibilities. One mechanism as suggested by Peiken, Lamberta and Seriff (1974) might be an initial pneumomediastinum with leakage of air through the mediastinal pleura causing bilateral pneumothorax. In the world literature reviewed by Peikin and others only 15 cases of mediastinal emphysema complicating acute miliary tuberculosis have been reported. In none of these, however, was pneumothorax present and in the present series the patient with a pneumomediastinum did not have a pneumothorax. We have reported another case of acute miliary tuberculosis with pneumomediastinum in a seven year old child (Narang and Mital, 1967) and this is included in Peikin’s review. In 2 of our cases the pneumothorax was bilateral but there was no evidence of pneumomediastinum and pneumomediastinum was not present in the 3 cases of bilateral pneumothorax reported in the literature. Thus from this experience pneumomediastinum and interstitial emphysema does not seem to be a likely cause of pneumothorax in acute miliary tuberculosis. Another possible mechanism might be caseation or necrosis of subpleural miliary nodules and their subsequent rupture through the pleura. Alternatively bullous lesions might form near miliary tubercles which rupture to produce a pneumothorax. Either one or both of these mechanisms may be operative in acute miliary tuberculosis complicated by pneumothorax. References Narang, R. K., Et Mital, 0. P. (1967). Interstitial and mediastinal emphysema complicating acute miliary tuberculosis. Indian Journal of Chest Diseases, 9, 58. Peiken, A. S., Lamberta, F., 8 Seriff, N. S. (1974). Bilateral recurrent pneumothoraces. A rare complication of miliary tuberculosis. American Review of Respiratory Diseases, 110, 512.