Spontaneous pneumothorax results from the accumulation of air in the pleural space, leading to partial or complete collapse of the affected lung. Primary spontaneous pneumothorax (PSP) classically occurs in young, tall, thin males without clinically apparent underlying lung disease, whereas secondary spontaneous pneumothorax (SSP) occurs in association with structural pulmonary pathology. Tobacco use is a well-established risk factor for spontaneous pneumothorax and may contribute to structural changes that persist after smoking cessation. We present an atypical case of spontaneous pneumothorax in a 65-year-old obese female with a remote smoking history who presented with acute dyspnea and right-sided pleuritic chest pain. Imaging demonstrated a large right-sided pneumothorax and a 1.7 cm apical bleb. The patient underwent chest tube thoracostomy with successful lung re-expansion and clinical improvement. Although the patient carried a documented clinical diagnosis of PSP, occult SSP could not be fully excluded given the patient’s prior tobacco exposure and structural pulmonary abnormality. This case highlights the diagnostic overlap that may exist between PSP and SSP in patients who do not fit the classic demographic profile.
Rasheed et al. (2026) studied this question.