Recurrent Pneumothorax With Bronchopleural Fistula in Primary Multidrug-Resistant Pulmonary Tuberculosis: A Challenging Case

Multidrug-resistant pulmonary tuberculosis (MDR-TB) complicated by recurrent pneumothorax and bronchopleural fistula (BPF) presents a major clinical challenge. We report a 41-year-old man with primary MDR-TB and a history of moderate smoking who developed recurrent secondary spontaneous pneumothorax due to BPF. Initial management included individualized MDR-TB therapy, chest tube drainage, and intrapleural catheter placement. Persistent air leak (PAL) and recurrent pneumothorax required surgical intervention. After 2 months of anti-TB therapy, he underwent video-assisted thoracoscopic surgery (VATS) for fistula repair, followed by open thoracotomy with decortication and lung laceration repair 3 months later. Imaging revealed paraseptal emphysema, loculated hydropneumothorax, and bilateral fibrocavitary changes consistent with active pulmonary tuberculosis. The patient showed clinical and radiological improvement up to 9 months of therapy, without recurrent pneumothorax or significant air leak. This case highlights the importance of early diagnosis, timely surgery, and multidisciplinary management in managing complex MDR-TB complications and preventing recurrence.