Ann Thorac Surg 2010;90:304-305. doi:10.1016/j.athoracsur.2009.12.077
© 2010 The Society of Thoracic Surgeons
Case Reports
Multimodality Management of Extensive Tuberculous Bullous Disease of Lung With Bilateral Pneumothorax
Ikram Chaudhry, FRCS(CTh)*,
Shoukat Bojal, FRCS,
Adel Attia, MD,
Aziz Nwasser, MD
Department of Chest Surgery, and Chest Medicine, King Fahad Specialist Hospital, Dammam, Saudia Arabia
Accepted for publication December 29, 2009.
* Address correspondence to Dr Chaudhry, PO Box 15215, Kingdom of Saudi, Arabia Dammam, 31444 (Email: drihc{at}hotmail.co.uk).
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Abstract
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Diffuse bullous disease of the lung in miliary tuberculosis associated with bilateral pneumothorax is a rare entity with grave prognosis. We describe the case of a 24-year-old woman in her first trimester of pregnancy with extensive bilateral pulmonary infiltrates as seen on computed tomographic scan of the lung. She had simultaneous bilateral pneumothorax that was managed with antituberculous therapy, steroids, and surgery for failure of lung expansion.
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Introduction
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Mycobacterium tuberculosis commonly affects the lungs. Worldwide, the number of pulmonary tuberculosis patients is rising due to resistance of antitubercular treatment and immunosuppression. Chronic cough, hemoptysis, pneumothorax, and bronchiectasis are more frequent presentations of tuberculosis [1]. Apical blebs are noticed in a few cases; however, we believe that diffuse pulmonary bullae over the entire surface of both lungs have not been reported in the literature to date.
A 24-year-old woman (weight, 27 kg) in her first trimester of pregnancy presented with intermittent pyrexia and night sweats, associated with cough and shortness of breath on exertion. There was weight loss and loss of appetite during this period. Prior to the her referral to the district hospital, the woman was being seen by her general practitioner who was treating her with antibiotics (erythromycin) and antitussives for 4 weeks.
Her sputum was positive for acid fast bacillus and her chest roentgenogram revealed diffuse bilateral pulmonary infiltrates. A diagnosis of miliary tuberculosis was made. After medical termination of her pregnancy, she was treated with antituberculous chemotherapy. She was started on isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months for the initial phase, including prednisolone. After a 3-week hospital stay she was discharged home.
She was admitted into our tertiary care hospital with sudden onset of chest pain and shortness of breath. On admission she had a chest roentgenogram that confirmed bilateral pneumothorax (Fig 1A). This was managed by inserting bilateral 28-French intercostal drains. Despite the drains, which were on –20 cm H2O, both of her lungs failed to expand and she had shortness of breath and became hypoxic. She was transferred to the intensive care unit for monitoring and respiratory care. She was continued on the antituberculous regimen. The computed tomographic chest scan showed bilateral pulmonary infiltrates (Fig 1B). We managed her treatment conservatively for 6 weeks, but there was a persistent bilateral air leak and failure of lung expansion. By this time she had completed 2 months of the initial phase of treatment, and 1 month of the continuation phase of treatment with antituberculous therapy of ethambutol and rifampicin, because her culture report revealed resistance to isoniazid. Her 
-1 antitrypsin was normal and the polymerase chain reaction was positive for tuberculosis. At this stage we decided to proceed with surgery.
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Fig 1. (A) Chest roentgenogram showing bilateral pneumothorax and multiple miliary opacities. (B) Computed tomographic (CT) scan of the chest revealing pneumothorax and ground glass appearance of lung opacities. (C) Follow-up chest roentgenogram showing both lungs clear and fully expanded. (D) Follow-up CT chest scan showing good recovery.
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We used a median sternotomy and found both lung surfaces entirely covered by bullae of variable sizes (Fig 2). A lung biopsy and bilateral parietal pleurectomy were done. An argon beam was applied to the ruptured bullae. As a routine procedure, two chest drains were left in each hemithorax and the sternotomy was closed using a standard fashion. The patient was transferred back to the intensive care unit in stable hemodynamic condition and her postoperative chest roentgenogram showed both lungs were fully expanded. After 48 hours, she was transferred to the ward where she remained stable with good O2 saturation. She made an excellent recovery with the multidisciplinary management.
Her appetite improved and she started gaining weight. The histopathologic results confirmed caseating granuloma with epitheloid cells consistent with pulmonary tuberculosis.
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Comment
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The incidence of drug-resistant pulmonary tuberculosis is rising all over the world. The failure rate is as great as 30% [2, 3].
Incidence of bilateral pneumothorax in miliary tuberculosis is only 1.3% to 1.5% [4]. Diffuse bullous disease of lung in miliary tuberculosis with bilateral pneumothorax is a rare and lethal condition having a mortality of more than 50% [5].
Pneumothorax in miliary tuberculosis is caused by caseation necrosis of a pulmonary nodule or by the rupture of multiple bullae formed due to emphysematous changes in the lungs.
Management of patients with such a condition is very challenging. The patient should have antituberculous treatment for 3 months before any surgical intervention [6, 7].
The surgical options for such cases are chemical pleurodesis, parietal plurectomy by video assisted thoracic surgery or an open method with stapling of the leaking bullae or argon beam ablation.
In conclusion, the management of such cases is demanding because of repeated rupture of bullae leading to recurrent pneumothoraxes. A multimodality treatment approach by a pulmonologist, an intensivist, a thoracic surgeon, a nutritionist, and a physiotherapist led to her excellent recovery. In addition to medical treatment, surgery for failure of lung expansion made a dramatic clinical and radiologic recovery as shown in Figures 1C and 1D, and she returned back to a normal life. We believe that no such case of extensive bilateral tubercular bullous disease of the lungs has been reported in the literature to date (Fig 2).
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References
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- Khan MA, Kovnat DM, Bachs B. Clnical and roentgenographic spectrum of pulmonary tuberculosis in the adult Am J Med 1977;62:31.[Medline]
- Frieden TR, Sterling T, Baplos-Mendes A, Kilburn JO, Cauthen GM, Dooley SW. The emergence of drug resistant tuberculosis in New York City N Engl J Med 1993;328:521-526.[Medline]
- Goble M, Iseman, MD, Madsen LA, Waite D, Ackarson L, Horsburgh CR. Treatment of 171 patients with pulmonary tuberculosis resistant to INH and rifampin N Engl J Med 1993;328:527-532.[Medline]
- Mert A, Bilr M, Akman C. Spontaneous pneumothorax: a rare complication of miliary tuberculosis Ann Thorac Cardiovasc Surg 2001;7:45-48.[Medline]
- Inouye WY, Berggren RB, Johnson J. Spontaneous pneumothorax Dis of Chest 1970:57-65.
- Peiken AS, Lamberta F, Sariff NS. Bilateral recurrent pneumothoraces: rare complication of miliary tuberculosis Am Rev Respir Dis 1974;110:512-517.[Medline]
- Graf-Deuel E, Knoblauch A. Simultaneous bilateral spontaneous pneumothorax Chest 1994;105:1142-1146.[Abstract/Free Full Text]
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Abstract
Introduction
