Conservative management of prolonged air leak following tension pneumothorax in cavitary pulmonary tuberculosis: a case report

BACKGROUND: Secondary spontaneous pneumothorax is a recognized complication of pulmonary tuberculosis; however, presentation with tension physiology followed by prolonged air leak may create diagnostic and management challenges, particularly when tuberculosis is not known at presentation. CASE PRESENTATION: We report a 20-year-old male with a 3 pack-year smoking history and no known prior lung disease who presented with dyspnea, left-sided pleuritic chest pain, productive cough, and constitutional symptoms. During the initial emergency assessment, unilateral chest findings raised concern for a left-sided pneumothorax. Urgent chest radiography obtained during this process showed a large left-sided pneumothorax with mediastinal shift, and emergency needle decompression was performed as a temporizing maneuver, followed directly by placement of a 28-Fr left chest tube. Persistent incomplete lung re-expansion and continuous air bubbling prompted further evaluation. Chest computed tomography revealed multiple left-sided cavitary lesions with surrounding parenchymal infiltrates, and sputum Ziehl-Neelsen staining was positive for acid-fast bacilli in three samples, supporting active cavitary pulmonary tuberculosis in the clinical and radiographic context. Standard anti-tuberculosis therapy was initiated. Despite early symptomatic improvement and substantial lung re-expansion, air leakage persisted. Because the patient maintained adequate oxygenation, controlled drainage, and no evidence of pleural sepsis or respiratory deterioration, conservative management was continued under thoracic surgical supervision with ambulatory drainage and close follow-up. The air leak resolved 61 days after hospital discharge, and the chest tube was removed without subsequent clinical recurrence. CONCLUSIONS: This case highlights that emergency decompression should not preclude continued etiologic evaluation when pneumothorax is accompanied by constitutional symptoms, incomplete lung re-expansion, persistent air leakage, or parenchymal abnormalities. It also illustrates that, in carefully selected clinically stable patients with adequate drainage and close supervision, prolonged air leak in active cavitary tuberculosis may be interpreted within the broader clinical trajectory rather than by duration alone.