Pneumothorax with pneumomediastinum and subcutaneous emphysema in a tuberculosis child

INTRODUCTION
Pneumothorax is the presence of air within the pleural space. It is considered one of the most common forms of thoracic disease and is classified as spontaneous (not caused by trauma), traumatic, or iatrogenic. Spontaneous pneumothorax can be either primary (occurring in persons without clinically or radiologically apparent lung disease) or secondary (in which lung disease is present and apparent). It occurrence in pediatric patients is not common. 1,2,3

Fig. 2. Roentgenogram of chest obtained about 1 month after

the introduction of tuberculostatic drugs

Pneumothorax as a complication of childhood tuberculosis is extremely unusual although it is occurrence as a complication of adult cavitary pulmonary tuberculosis is well documented. In childhood tuberculosis, pneumothorax might be occur following ruptured bullous emphysematous lesions, which as complication of primary pulmonary tuberculosis during healing process after the introduction of anti tuberculous.

The addition of corticosteroid to the antituberculous therapy seems to potentiate this effect. ^1,4,5

Estrera (1992) observed 120 patients with spontaneous pneumothorax admitted from 1983-1991 to Parkland Memorial Hospital in Dallas, 31 out of 120 patients (26%) had localized areas of emphysema, bullas, or blebs. In which 7 of them were infected with M. tuberculosis.⁶

Pneumothorax and pneumomediastinum very often occur together. The important clinical point in this relationship is that when pneumothorax exists the presence of pneumomediastinum may be overlooked.⁷

Emphysema subcutis most commonly caused by pneumomediastinum or pneumothorax, whenever free air finds its way into the subcutaneous tissue.

It is usually self limited and, although it can be uncomfortable, requires no specific treatment. Resolution occurs by resorption of subcutaneous air after elimination of its source.^1,8,9

The purpose of this paper is to present a rare case of tuberculosis that developed pneumothorax, pneumomediastinum and emphysema subcutis.

CASE REPORT

A 2½ years old boy was brought to the emergency department on March 21, 2002 with main complaint of dyspnoea.

According to his mother, he had difficulty in breathing since 2 weeks prior to admission. The symptom was preceded by cold and coughing which became worsening especially at night. He developed chest pain without any fever. The mother noted that his neck gradually swollen and difficulty in swallowing the past 3 days prior to admission.

He was discovered to have TB infection 3 months prior to admission and had been on TB medication since then. He was planned to have 6 months TB treatment with Pirazinamide 1x230mg, Isoniasid 1x135mg, Rifampicin 1x90mg and B6 1x10mg for the first 2 months and followed by Isoniasid 1x135mg, Rifampicin 1x90mg and B6 1x10mg for the rest 4 months.

He was diagnosed to suffer from TB based on history included three months of coughing, anorexia, losing some weight (his weight was 9 kgs, lost 2 kg in 2 months) and low grade fever for about two weeks. The mother is known as the source contact as she had ever haemoptoe and has been on medication for 4 months.

Although the patient had completed immunization, his BCG scar was negative, and so was his Tuberculin test.

Chest x-ray showed infiltrates on both lungs. About one month after the introduction of tuberculostatic drugs, his chest x-ray showed multiple blebs on the right lung, however he had good response toward tuberculostatic drugs with good clinical condition.

He was advised to come routinely to the out patient clinic for routine evaluation or come to the emergency department at anytime if he had breathing problems, but this patient had never come for routine follow up until he developed of symptom previously mentioned above.

Physical examination on admission on March 21 2002 revealed, a malnourished boy who looked ill and dyspnoeic. There were no sign of cyanotic, anaemic nor icteric. His body weight was 10 kg, with nutritional status 77%.

The pulse rate was 112 beats per minutes, and the respiratory rate was 60 times per minute with positive nasal flares. His temperature was 37⁰C. His neck was swollen with subcutaneous crepitation. Subcutaneous crepitation was also noted on the area of hemithorax anterior dextra.

Retraction of the intercostals space and epigastric area was noted. On auscultation breath sound was decreased on the right lung despite increased resonance on percussion of the same side of the lung.

The liver was about 2 cm below the costal margin and spleen was not enlarged. The extremities were warm, no oedema were noted.

The blood gas analysis on admission revealed the following pH: 7.303; pCO2: 30.7; pO2:80.2; HCO3:14,9; BE: -11.5.

Laboratory examination on admission revealed the following: Hb: 9.8 g/dl, Leucocyte: 9700/cmm, Thrombocyte was sufficient in number, ESR: 20/hour, with differential count of: 3/-/- /-/20/70/-.

Chest x-ray on admission revealed: Right lung was collapse; there was no lung tissue on the right hemithorax with multiple blebs. Lucent appearance of the soft tissue on thoracic walls dextra/sinistra. These appearances indicated pneumothorax on the right lung with multiple blebs and subcutaneous emphysema.