Secondary spontaneous pneumothorax due to extensive pulmonary tuberculosis in a patient with acute hepatitis B flare: clinical challenges and therapeutic decision making-a case report.

内容摘要

Secondary spontaneous pneumothorax (SSP), particularly when complicated by a persistent air leak, is an uncommon but serious manifestation of active pulmonary tuberculosis. Such cases often require pleural drainage or surgical intervention. Management becomes significantly more challenging when patients present with extensive pulmonary disease, compromised general condition, and severe comorbidities. We describe a 28-year-old male with bilateral extensive pulmonary tuberculosis, persistent right-sided pneumothorax, and a severe acute flare of chronic hepatitis B. Conventional management, including pleural drainage and chemical pleurodesis, was unsuccessful, and the patient's acute hepatic injury precluded the use of standard first-line anti-tuberculosis therapy. The primary clinical dilemma involved balancing the need for surgical repair of the persistent air fistula against the prohibitive perioperative risks posed by his hepatic dysfunction and poor systemic condition. A conservative, individualized medical strategy-comprising modified anti-tuberculosis therapy, supplemental oxygen, nutritional optimization, and comprehensive liver support-was selected. Over 6 months, the patient demonstrated progressive improvement in hepatic function and overall physical status, substantial radiologic recovery of pulmonary lesions, and complete resolution of the right pneumothorax. This case highlights that a carefully tailored, conservative medical approach may yield favorable long-term outcomes in SPP secondary to pulmonary tuberculosis, particularly in patients with significant surgical contraindications. Optimizing anti-tuberculosis therapy remains central to promoting lung parenchymal healing and resolving pneumothorax. A rare case of persistent pneumothorax caused by severe pulmonary tuberculosis in a young man with acute hepatitis B demonstrates how individualized medical treatment enabled full recovery without the need for high-risk surgery. This report describes a rare and medically complex case involving a 28-year-old man who developed a persistent pneumothorax—a serious complication where air continuously leaks from the lung into the chest cavity—caused by severe pulmonary tuberculosis. In most situations, this condition requires a chest tube or even surgery to repair the leak. What makes this case unusual is that the patient was also experiencing a severe flare of chronic hepatitis B, leading to significant liver failure. This prevented the use of standard tuberculosis medications and made surgery extremely risky. As a result, the medical team faced limited treatment options and had to make difficult decisions. Because of the high surgical risk, doctors used a highly individualized, non-surgical treatment strategy. They selected TB medications that were safer for the liver, provided active liver-supportive therapy, oxygen, and nutritional care. Although imaging continued to show a large and persistent lung collapse, the patient remained clinically stable. As the TB infection came under control, his lung slowly improved without surgical intervention. After six months of careful monitoring and tailored treatment, the patient’s liver function recovered, the TB-related lung damage healed, and the collapsed lung fully re-expanded. He was able to return to normal daily life. This rare and challenging case demonstrates that in certain high-risk patients—those who cannot tolerate surgery or standard TB treatment—individualized conservative management can still lead to full recovery. Sharing this experience may help clinicians facing similar difficult situations make safer, more effective decisions for their patients.