An unusual cause of pneumomediastinum and acute respiratory distress syndrome

Background Progressive acute respiratory failure with Mycobacterium tuberculosis (TB) in immunocompetent individuals is rare, and if detected early, diagnosis and treatment dilemmas can be limited. We report here a unique case of respiratory failure due to tubercular spontaneous pneumomediastinum complicated by acute respiratory distress syndrome (ARDS). Case presentation A 24-year-old male of low socioeconomic background presented with shortness of breath, dry cough, and fever for 7 days, which was accompanied by weight loss and a reduced appetite. The patient had tachypnea and hypoxemia (SpO(2) = 86%). The patient's condition deteriorated (SpO(2) = 72% with 12 L min(-1)of O-2 delivered using a non-rebreather mask), and he was intubated using a lung-protective approach with a tidal volume of 350 mL (6 mL kg(-1)), positive end-expiratory pressure (PEEP) of 5 cm H2O, RR of 20 cycles/min, a flow rate of 35 L min(-1), and FiO(2) of 0.6. High-resolution computer tomography of the thorax showed multilobar consolidation, pneumomediastinum, and extensive subcutaneous emphysema with left-sided pneumothorax. Subsequently, a left-sided tube thoracostomy was carried out. The PaO2/FiO(2) (P/F) ratio immediately after intubation was 130 and rose to 170 post-thoracostomy, which was suggestive of moderate ARDS. Bacterial and fungal colonies detected from the blood and endotracheal aspirate were normal. However, for the endotracheal aspirate, the cartridge-based nucleic acid amplification test (CBNAAT) detected TB with no rifampicin resistance. The patient was started on anti-tubercular therapy (ATT). Despite ATT, the patient developed circulatory shock and died after 4 days. Conclusions In young patients with acute spontaneous pneumomediastinum and ARDS, TB infection should be considered during initial diagnostics. This consideration may lead to timely treatments and improved patient survival.