Tension Pneumothorax

While watching TV, a 32-year-old man experienced acute right-sided pleuritic pain and was taken to the emergency department. He was seropositive for HIV but had never had Pneumocystis carinii pneumonia (PCP) and was not taking aerosolized pentamidine. Physical examination revealed hyperresonance with significantly decreased breath sounds over the right hemithorax.

The patient's condition deteriorated rapidly, and he required immediate intubation and ventilatory support. This chest film, taken during preparation for bedside thoracotomy to place a chest tube, showed a right-sided tension pneumothorax (small arrow) with collapsed right lung (large arrow) and contralateral mediastinal shift. A film taken after insertion of the tube showed fully expanded lungs with diffuse bilateral interstitial infiltrates. Examination of endotracheal tube aspirate revealed P carinii.

Air continued to leak into the pleural space despite chest tube drainage. The patient was treated with trimethoprim-sulfamethoxazole, but he died 2 weeks later of severe sepsis and disseminated intravascular coagulopathy.

Spontaneous pneumothorax associated with PCP is common among patients with AIDS. The prognosis is poor, since resolution of the pneumothorax occurs far less frequently than in patients who do not have AIDS. Early consideration of pleurodesis-as soon as air leakage stops-is encouraged because of the high incidence of recurrent air leakage.