ABSTRACTSecondary spontaneous pneumothorax is a pneumothorax that occur spontaneously in patient with underlying lung disease such as pulmonary tuberculosis (PTB) or chronic obstructive pulmonary disease (COPD). This is a case of 29-year-old gentleman with recurrent secondary spontaneous pneumothorax with background history of PTB which was complicated with subcutaneous emphysema and need for surgical intervention. Keyword: Spontaneous Pneumothorax, Pulmonary Tuberculosis, Subcutaneous EmphysemaINTRODUCTIONPneumothorax is defined as presence of air in the pleural space. It can occur spontaneously in the absence of trauma or as a result of trauma/injury to the chest (Davidson). Spontaneous pneumothorax can further be divided into primary and secondary. Primary spontaneous pneumothorax (PSP) occur in patient with no underlying lung disease and usually happened in male with tall-thin body shape and smoking. Annual incidence of PSP is 7.4-18 cases (age-adjusted incidence) per 100,000 population in males and 1.2-6.0 cases per 100,000 population in females. (1) PSP usually occurs between age of 10-30 years. (2) Secondary spontaneous pneumothorax (SSP) usually occur in patient with underlying lung diseases such as COPD, emphysema, cystic fibrosis, tuberculosis or lung cancer. In patient with lung diseases, the function of the lung is already compromised. (1) Therefore, SSP usually present as potentially life threatening disease and need immediate action. Peak incidence of SSP usually between 60-64 years depending on underlying condition. (1,3)CASE REPORTA 29-year-old Malay gentleman, an active smoker of 8 pack-year, with history of childhood bronchial asthma and previous history of Pulmonary Tuberculosis (PTB) completed 6 months of anti-tuberculosis treatment in the past 4 months presented with sudden onset of left sided chest pain 1 hour prior to presentation. Prior to that, he had 4-day history of productive cough with whitish sputum about 1 table spoon associated with runny nose. On the day of admission, his cough worsening during midnight. He coughed continuously until he had experienced sudden onset of left sided chest pain which was pleuritic in nature. The pain was continuous, sharp in nature, aggravated lying flat and relieved by sitting. His pain radiated to the epigastrium and the back and pain score was 5/10. The chest pain was associated with shortness of breath. Otherwise, he had no history of fever or sick contact, palpitation, numbness over left arm or profuse sweating, no haemoptysis and no water brash symptoms. He also had no history of distant travelling or prolonged bed rest.On past medical history, he had history of childhood asthma until his primary school and was resolved after that. After he was diagnosed with TB which was 8 months ago, his asthma recurred and he was on MDI Ipratropium Bromide/ Fenoterol 2 puffs twice daily and MDI Salbutamol on PRN basis. His asthma usually triggered by cold environment and infection. His last nebulisation was 8 months ago. He has no daytime and nocturnal symptoms. He had an activity limitation whereby he cannot do heavy work or work in a rush. He used his reliever inhaler about once in two weeks. Therefore, his asthma is partly controlled.He was diagnosed of having PTB 9 months ago when he had history of productive cough for 2 years and presented with chest pain and shortness of breath. His Acid-Fast Bacilli (AFB) smear was positive and was then started on anti-tuberculous treatment. He completed 2 months of intensive phase and 4 months of maintenance phase. His repeated AFB smear was negative after the treatment.In the Emergency Department (ED), he was given 1 nebuliser. However, the shortness of breath and the pain still persist. He was initially thought of having gastritis and was given medications for that. The pain was not resolved and then he was sent for chest radiograph. His chest radiograph (Figure 1) revealed of left sided pneumothorax. Chest tube was inserted immediately by the emergency team and he was admitted to the ward. His symptoms were improving after the chest tube inserted. His Arterial Blood Gas (ABG) was also taken in ED under Face Mask 6L/min revealed partially compensated respiratory acidosis with pH of 7.339.On day 1 of admission, he developed subcutaneous emphysema over the neck, trunk, back, upper limb, abdomen and upper thigh. Chest radiograph was done revealed the chest tube was inadequately anchored which causes the emphysema to develop. Physical examination was done on day 7 of admissions. On general examination, he was alert and conscious. He was on oxygen supplementation via nasal prong on 3L/min. There was a chest tube inserted on the left chest connected to the drainage bottle. There were 2 suction cannulas over both sided of anterior chest connected to a suction pump. His vital signs were all normal with temperature of 37 degree Celsius, blood pressure of 120/70, respiratory rate of 20 breaths per minute, pulse rate of 88 beats per minute and oxygen saturation of 98% under nasal prong 3L/min. Hand examination showed no clubbing and no peripheral cyanosis. Conjunctiva was pink. Oral hydration and hygiene were good and there was no pedal oedema. On respiratory examination, the chest was moving symmetrically on both sides. There was no chest wall deformity seen and no surgical scar. On palpation, there was crepitus felt over the neck, trunk, back, upper arm and upper thigh. Chest expansion is symmetrical bilaterally. Tactile and vocal fremitus were normal. On percussion, all were resonance. On auscultation, there was vesicular breath sound which was reduced over the left side and there were generalised rhonchi on both side of the lungs. Other systemic examination revealed no remarkable findings. During his hospital stay, all his blood parameters were within normal limit except White Cell Count of 13.7 x 109/L which was leucocytosis with predominant neutrophils. Therefore, he was given IV Amoxicillin-Clavulinic Acid 1.2g TDS. Sputum AFB times 3 were all negative. He was scheduled for CECT scan of thorax on day 14 of admission. CECT scan revealed left pneumothorax with multiple apical bullae, chronic lung changes with superimposed infection and subcutaneous emphysema. His case was consulted by a respiratory consultant from HTAA. He was planned to be referred to cardiothoracic team for surgical pleurodesis or medical pleurodesis by talc. He was reviewed by the cardiothoracic team during the clinic in HTAA. During the appointment, he developed mild shortness of breath. He was planned by the cardiothoracic team for Video-Assisted Thoracoscopic Surgery (VATS) keep in view of surgical pleurodesis if recurrent pneumothorax. Urgent chest radiograph revealed left sided pneumothorax and left Saldinger chest tube was inserted. In view of recurrent pneumothorax, he was referred back to cardiothoracic surgeon in HTAA for further intervention. DISCUSSIONBased on the case reported above, it describes a case of SSP that occur on patient with underlying bronchial asthma and previous history of PTB. He presented with 4-day history of cough and sudden onset of pleuritic left sided chest pain that radiate to the epigastrium and the back. He was given a nebulisation of Ipratropium Bromide and Salbutamol, however he did not response to it. He was then given medication for gastritis which ended up not resolving his symptoms. Therefore, there are few important differential diagnoses that must be considered which are pneumothorax, acute coronary syndrome, gastritis and pulmonary embolism. In this case, SSP was diagnosed when the patient was re-examined after non-response to appropriate therapy for gastritis. About 1-3% of hospitalized TB patients developed SSP. It was due to rupture of tuberculous cavity into the pleural space. (4) There was a study in Japan reported that 22.8% patient with tuberculosis developed secondary spontaneous pneumothorax. (5) Diagnosis of SSP is established by detection of visceral pleural line on the chest radiograph. (4) In this patient’s chest radiograph (Figure 1), visceral pleural line was detected over the left side of the chest. The management of SSP depends on the severity of the patient’s symptoms and size of pneumothorax. Patient who are clinically stable with small pneumothorax can be observed. Patient who is clinically stable but has large pneumothorax should have a chest tube inserted while patient who is clinically unstable, need a chest tube placed regardless of the size of pneumothorax. In this patient, he was clinically unstable with tachypneoa, therefore chest tube was inserted as an immediate management. Moreover, pleurodesis is one the way to prevent recurrent SSP. There are 2 types of pleurodesis which are medical and surgical pleurodesis. Medical pleurodesis is the instillation of substance into the pleural space which will cause aseptic inflammation with dense adhesions leading to pleural symphysis. Tetracycline or graded talc are among the sclerosant agent that have been used in medical pleurodesis. However, majority of the cases, the prevention of recurrences is usually done surgically via open or VATS as the rate of recurrence following surgical pleurodesis is lesser as compared to medical pleurodesis. (6) British Thoracic Society recommends that pleurodesis is reserved for patient with unresolved air leak or recurrent pneumothorax. (7) There are few indications that need surgical intervention such as: (8)• Persistent air leak for longer than 7 days• Recurrent, ipsilateral pneumothorax• Contralateral pneumothorax• Bilateral pneumothorax• First-time presentation in a patient with a high-risk occupation (for example: diver, pilot)As in this case, he was initially planned for VATS as the primary procedure. However, after that he developed second episode of ipsilateral SSP, he was indicated to undergo surgical intervention. As described above, his pneumothorax was complicated with subcutaneous emphysema. Subcutaneous emphysema (SE) occurs when there is leakage of air into the subcutaneous tissue. It can be caused by blunt or penetrating trauma, pneumothorax, infection, malignancy or as a complication of surgical procedures. Most common signs and symptoms are swelling, dyspnoea, crepitus and pneumothorax. Based on one study by Iran researchers, chest trauma is the major cause of subcutaneous emphysema. Other main causes of SE along with pneumothorax is improper functioning of the chest tube which similarly happened in this patient. (9) His chest tube was inadequately anchored during insertion which complicates him with SE. His SE was managed by inserting 2 suction cannula over the anterior chest to remove the air faster. Other managements includes bed rest, control of pain and supplemental oxygen. In the same study, patients were managed by doing 2 infraclavicular incisions and eventually lead to rapid resolution of SE. (9)ISLAMIC PERSPECTIVEIn regards to the patient’s social issue, he is an active smoker. Based on Fatwa, smoking is prohibited in Islam. Smoking is Haram because of its many harmful effects and bad consequences. Allah says in the Quran in Surah Ar’auf Chapter 7 Verse 157, “This Prophet asked you to do things which are good for you so take what he gives you which is lawful and good and he prohibits things which are unlawful, the things which are bad for you.” (10) Bases on this verse, Allah has forbidden all that is evil and harmful for his slaves. Therefore, I would like to advice and encourage the patient to stop smoking as he is a Muslim. Smoking cessation will improve his health and eventually improves the quality of life.