Spontaneous pneumothorax as pulmonary air leak syndrome in rheumatoid arthritis: a case report and literature review

Abstract Rheumatoid arthritis (RA) is a chronic inflammatory disease with systemic extra-articular manifestations, including pleuropulmonary involvement. Pulmonary air leak syndrome is an uncommon complication of RA and may manifest as pneumothorax, pneumomediastinum, pulmonary interstitial emphysema, or subcutaneous emphysema. We report the case of a 61-year-old woman with seropositive RA who presented with fever, productive cough, pleuritic chest pain, and acute hypoxic respiratory failure shortly after initiation of tofacitinib. She was initially treated for pneumonia and improved, but on hospital day seven she developed acute respiratory deterioration with a large right-sided pneumothorax requiring tube thoracostomy and subsequent repositioning for persistent air leak. Her condition improved with drainage and supportive care, and she was discharged with outpatient pulmonary follow-up. Retrospective review of imaging did not demonstrate pulmonary nodules, suggesting that cough, bronchospasm, or fragile rheumatoid lung parenchyma may have contributed to alveolar rupture. This case highlights that pulmonary air leak syndrome, although rare, should remain in the differential diagnosis when patients with RA develop sudden respiratory worsening. Early imaging and timely pleural intervention are critical to prevent morbidity.