Secondary spontaneous pneumothorax due to extensive pulmonary tuberculosis in a patient with acute hepatitis B flare: clinical challenges and therapeutic decision making-a case report.

Secondary spontaneous pneumothorax (SSP), particularly when complicated by a persistent air leak, is an uncommon but serious manifestation of active pulmonary tuberculosis. Such cases often require pleural drainage or surgical intervention. Management becomes significantly more challenging when patients present with extensive pulmonary disease, compromised general condition, and severe comorbidities. We describe a 28-year-old male with bilateral extensive pulmonary tuberculosis, persistent right-sided pneumothorax, and a severe acute flare of chronic hepatitis B. Conventional management, including pleural drainage and chemical pleurodesis, was unsuccessful, and the patient's acute hepatic injury precluded the use of standard first-line anti-tuberculosis therapy. The primary clinical dilemma involved balancing the need for surgical repair of the persistent air fistula against the prohibitive perioperative risks posed by his hepatic dysfunction and poor systemic condition. A conservative, individualized medical strategy-comprising modified anti-tuberculosis therapy, supplemental oxygen, nutritional optimization, and comprehensive liver support-was selected. Over 6 months, the patient demonstrated progressive improvement in hepatic function and overall physical status, substantial radiologic recovery of pulmonary lesions, and complete resolution of the right pneumothorax. This case highlights that a carefully tailored, conservative medical approach may yield favorable long-term outcomes in SPP secondary to pulmonary tuberculosis, particularly in patients with significant surgical contraindications. Optimizing anti-tuberculosis therapy remains central to promoting lung parenchymal healing and resolving pneumothorax.