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CASE IN POINT - CLINICS IN PULMONOLOGY
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 192-194

Miliary tuberculosis with bilateral recurrent pneumothoraces


1 Department of Pulmonary Medicine, ESI-PGMSR, New Delhi, India
2 Department of Pathology, ESI-PGMSR, New Delhi, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Sonam Spalgais
Senior Resident, Department of Pulmonary Medicine, ESI-PGMSR New Delhi - 110 015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/astrocyte.astrocyte_58_17

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  Abstract 


A 13-year girl presented with fever, chest pain, cough, and decreased appetite of 15 days. General and respiratory examination was normal. Routine investigations were normal. Sputum for AFB was negative. Chest X-ray revealed bilateral miliary nodules. Eye examination showed choroid tubercles with chorioretinitis. She was diagnosed as disseminated TB and started on ATT daily regime with oral prednisolone. After 5 days, she developed pneumothorax and ICD was inserted. CECT chest showed bilateral multiple miliary nodules with bilateral pneumothorax. She had recurrence (6 times) of Pneumothoraces during 3 months and managed with ICD. She underwent thoracoscopic surgical biopsy for confirmation of diagnosis. Immunohistocytology was negative for CD1a and HMB45. Biopsy was consistent with TB. The final diagnosis was miliary tuberculosis with bilateral recurrent Pneumothoraces. ATT continue for 9 months with tapering of steroid. Chemical pleurodesis was performed. She was followed up for 2 years with no recurrent of pneumothorax. Bilateral recurrent pneumothorax is rare complication of miliary TB.

Keywords: Bilateral pneumothorax, choroid tubercles, miliary tuberculosis, pleurodesis


How to cite this article:
Choudhari OK, Spalgais S, Ojha UC, Murar AK, Verma AK. Miliary tuberculosis with bilateral recurrent pneumothoraces. Astrocyte 2017;4:192-4

How to cite this URL:
Choudhari OK, Spalgais S, Ojha UC, Murar AK, Verma AK. Miliary tuberculosis with bilateral recurrent pneumothoraces. Astrocyte [serial online] 2017 [cited 2020 Jun 3];4:192-4. Available from: http://www.astrocyte.in/text.asp?2017/4/3/192/224197




  Introduction Top


Pneumothorax is a complication of pulmonary and pleural tuberculosis (TB) occurring in nearly 1.5% of the cases.[1] Pneumothorax is a rare complication of miliary TB.[2] Bilateral recurrent pneumothorax is seldom seen in patients of miliary TB.[3] We are reporting a case of bilateral recurrent pneumothorax in case of miliary TB managed with video-assisted thoracoscopic surgery (VATS) and antitubercular therapy (ATT) with chemical pleurodesis.


  Case Report Top


A 13-year-old young girl presented with complaints of fever, chest pain, cough, and decreased appetite of 15 days duration. There was no history of antitubercular therapy and contact history to TB. On examination, she was conscious, oriented, afebrile with SpO2 97% on room air, pulse rate 76/min, respiratory rate 18/min, and blood pressure 118/70 mmHg. There were no enlarged peripheral lymph nodes. Respiratory examination revealed bilateral vesicular breath sound with no added sound. Routine hematological and biochemical investigation were normal. Sputum direct smear for acid fast bacilli (AFB) by Ziehl–Neelson (ZN) staining was negative twice. Chest X-ray revealed miliary nodules in bilateral lung fields. Human immunodeficiency virus (HIV) serology was nonreactive. Ultrasound of the abdomen was normal. Her eye examination showed choroid tubercles with chorioretinitis with disc hemorrhage [Figure 1]a. She was diagnosed as disseminated TB (miliary and ocular). She was started on ATT daily regime with rifampicin (R), isoniazid (I), pyrazinamide (Z), and ethambutol €. Prednisolone was added in consultation with ophthalmologist for eye aliment. After 5 days of treatment, she was presented to the emergency department with sudden onset of breathlessness and nontraumatic left-sided chest pain. On examination, she was conscious oriented, respiratory distress with SpO2 80% on room air, pulse 136/min, respiratory rate 38/min, and blood pressure 90/60 mmHg. Respiratory examination revealed bilateral vesicular breath sound with decreased breath sounds on the left side. Chest X-ray showed pneumothorax on the left side. Inter-costal drainage (ICD) was put on left side and treatment was continued with ATT, oxygen inhalation, and other supportive care. Repeat X-ray of the chest showed right-sided pneumothorax on the 3rd day of admission and ICD was put on right side. Contrast-enhanced computed tomography (CECT) chest was done as patient has recurrent bilateral pneumothoraxes, and results showed bilateral multiple miliary nodules with pneumothorax [Figure 1]b. During 3 months of hospital stay, patient had recurrence (six times) of pneumothoraxes, which was managed with ICD. The dilemma of diagnosis was whether it was miliary TB, keeping other differentials such lymphangioleiomyomatosis (LAM), Langerhans cell histiocytosis, patient was considered for video-assisted thoracoscopic surgery biopsy. Biopsy showed epithelioid cell granuloma with Langham's type of giant cell. This was consistent with TB [Figure 1]c. Immunohistocytology of lung biopsy was also done and negative for CD1a and HMB45. The final diagnosis was miliary tuberculosis with bilateral recurrent pneumothoraxes. The treatment continued with ATT (HRZE) for 3 months and HRE for next 6 months with tapering of steroid dose after 2 months. Recurrent pneumothoraxes were treated with ICD. Chemical pleurodesis was performed after complete resolution of pneumothoraxes on both sides. She was followed up for next 2 years with resolution of TB and no recurrent of pneumothorax [Figure 1]d. Her spirometry before VATS showed force vital capacity (FVC) of 0.63 l (29%), force expiratory volume in 1st second (FEV1) 0.59 l (31%), and FEV1/FVC 93.20 (110), which improved after treatment with FVC of 1.95 l (87%), FEV1 1.84 (82%), and FEV1/FVC 94.41 (111%).
Figure 1: (a) Choroid tubercles with chorioretinitis with disc hemorrhage. (b) CECT chest: Bilateral multiple miliary nodules with left-sided pneumothorax. (c) Lung biopsy showed epithelioid cell granuloma with Langham's type of giant cell. (d) Chest X-ray showing resolution of military nodules and pneumothorax after completion of ATT and 6 months later.

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  Discussion Top


A secondary spontaneous pneumothorax (SSP) is defined as a pneumothorax that occurs as a complication of underlying lung disease. There are many lung diseases which can cause SSP, although the most commonly associated diseases are chronic obstructive pulmonary disease, cystic fibrosis, lung malignancy, TB, and pneumonia.[4] Cavitary pulmonary TB is the most common cause of pneumothorax in our country. Miliary TB is one of radiological pattern of TB, and is usually disseminated. Pneumothorax is a rare complication of miliary TB. Lui [5] in 2008 reported only 19 cases of pneumothoraxes as a complication of miliary TB, out of which 8 cases were bilateral. Bilateral recurrent pneumothoraxes is a rare entity limited to case reports/series.[4],[5] Pneumothorax in miliary TB usually develop during the treatment with ATT.[6] As in our case, the first episode of pneumothorax developed after 5 days of ATT.

Miliary TB is difficult to diagnosis as this form of TB is rarely sputum smear positive. It is difficult to confirm microbiologically, without any surgically intervention. Miliary TB is one form of disseminated TB, resulting from massive hematogenous dissemination of tubercle bacilli. Miliary pattern on chest radiograph is the hallmark of military TB.[7] Ocular involvement is common in military TB. Choroidal tubercles are pathognomonic of miliary TB and help in diagnosis.[7] As in our case choroid tubercles was positive on ophthalmological examination. Therefore, ophthalmological examination must be done in every miliary TB suspect.

The treatment option for pneumothorax is close needle aspiration and ICD with ATT. In our patient, there was recurrence of pneumothoraxes 6 times during 3 months of hospital stay. Her diagnosis was confirmed by miliary pattern, choroid tubercle with VATs biopsy, and she was treated with ATT, ICD, and chemical pleurodesis. The pathogenesis of pneumothorax in miliary TB is not well known till date, but few possible mechanisms suggested are listed in [Table 1].
Table 1: Possible mechanism of pneumothorax in miliary TB

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After ICD to re-expand the lung, further surgical treatment depends on the patient's general condition. If a patient's medical condition is good and can tolerate general anesthesia, VATS is recommended.[10] However, VATS for SSP is more complicated and higher morbidity compare to primary spontaneous pneumothorax. Therefore, clinical judgment is an important factor for ensuring optimal outcome. Our patient was a young girl with no history of chronic disease and dilemma over confirm diagnosis. Therefore, we judged that VATS biopsy and chemical pleurodesis would be safe and effective to confirm diagnosis and treat recurrent pneumothorax.

In conclusion, pneumothorax should be a suspect in sudden clinical deterioration in miliary TB during ATT. The ophthalmological examination along with miliary pattern of radiology should be perform in every suspected case of miliary TB to confirm diagnosis. Recurrent pneumothoraxes should undergo surgical treatment to confirm the diagnosis and treatment of pneumothorax, if clinically indicated and tolerable to patient.

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.



 
  References Top

1.
Aktogu S, Yorgancioglu A, Cirak K, Köse T, Dereli SM. Clinical spectrum of pulmonary and pleural tuberculosis: A report of 5,480 cases. Eur Respir J 1996;9:2031-5.  Back to cited text no. 1
    
2.
Arya M, George J, Dixit R, Gupta RC, Gupta N. Bilteral spontaneous pneumothorax in Miliary Tuberculosis. Indian J Tuberc 2011;58:125-8.  Back to cited text no. 2
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3.
Peiken AS, Lamberta F, Seriff NS. Bilateral recurrent pneumothoraces: A rare complication of miliary tuberculosis. Am Rev Respir Dis 1974;110:512-7.  Back to cited text no. 3
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4.
Noppen M, De Keukeleire T. Pneumothorax. Respiration 2008;76:121.  Back to cited text no. 4
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5.
Liu WL, Wang HC, Luh KT, Yang PC. Recurrent bilateral pneumothoraces: A rare complication of military tuberculosis. J Formos Med Assoc 2008;107:902-6.  Back to cited text no. 5
[PUBMED]    
6.
Khan NA, Akhtar J, Baneen U, Shameem M, Ahmed Z, Bhargava R. Recurrent pneumothorax: A rare complication of miliary tuberculosis. N Am J Med Sci 2011;3:428-30.  Back to cited text no. 6
[PUBMED]    
7.
Sharma SK, Mohan A. Disseminated and Miliary Tuberculosis. In: Sharma SK Mohan A, editor. Textbook of Tuberculosis. Second edition New Delhi: Jaypee Brothers Medical publishers; 2009. p. 493-6.  Back to cited text no. 7
    
8.
Meeklin MT, Macklin CC. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: An interpretation of the clinical literature in the light of laboratory experiment. Medicine (Baltimore) 1944;23:281-358.  Back to cited text no. 8
    
9.
Vidyasagar B, Murali S. A case of pneumothorax complicating acute miliary tuberculosis. Lung India 1988;16:128-9.  Back to cited text no. 9
    
10.
Yim AP, Ng CS. Thoracoscopy in the management of pneumothorax. Curr Opin Pulm Med 2001;7:210-4.  Back to cited text no. 10
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