Abstract Tuberculosis (TB) is uncommon in the United States, accounting for only 3% of global cases in 2023. Even rarer is miliary TB, representing just 1-2% of newly reported cases that same year. Miliary TB carries a high mortality rate in adults - estimated at 25-30% regardless of comorbidities.While pneumothorax is a well-recognized complication of cavitary pulmonary TB, it is an exceedingly rare manifestation of miliary TB. Pneumothorax ex vacuo represents an even rarer, distinct form of air accumulation within the thoracic cavity, typically arising from bronchial obstruction or failure of lung re-expansion following thoracentesis. When observed after thoracentesis, it is not considered a procedural complication but rather a consequence of underlying pleural disease or impaired surfactant production. We present a unique case of miliary TB with pleural involvement complicated by pneumothorax ex vacuo. A 28-year-old Venezuelan male immigrant with prior incarceration and known TB exposure presented with six weeks of hemoptysis, unintentional weight loss, and two weeks of fevers and night sweats. Chest CT revealed bilateral patchy infiltrates with innumerable centrilobular nodules, apical air-filled cavities, a large left pleural effusion, and pleural thickening with calcifications. With high clinical suspicion for pulmonary TB, empiric therapy was initiated.A chest tube was placed for the effusion; post-procedural imaging revealed pneumothorax ex vacuo. Sputum acid-fast bacilli (AFB) was positive, and miliary TB was confirmed via Mycobacterium tuberculosis polymerase chain reaction (MTB PCR) of pleural fluid. HIV testing was negative. Thoracic surgery recommended outpatient follow-up for possible thoracotomy after treatment completion. The chest tube was removed without complication, and the patient was discharged to a local TB clinic for continued care and contact tracing while awaiting surgical evaluation. Miliary TB presenting with pneumothorax ex vacuo has not been previously reported, underscoring the rarity of this case. In pneumothorax ex vacuo, the trapped lung may be irreversible and often requires definitive surgical management such as pleurodesis, decortication, or thoracotomy. Management of our patient was further complicated by active TB, necessitating prolonged antimicrobial therapy before surgical correction could be considered. Because no prior cases have been reported, mortality in miliary TB complicated by pneumothorax ex vacuo cannot be established; however, mortality associated with miliary TB alone remains high. Early CT imaging versus pleural manometry prior to thoracentesis may help identify patients at increased risk for pneumothorax ex vacuo. This abstract is funded by: None
Porzenski et al. (Fri,) studied this question.