A Case Report of Spontaneous Subcutaneous Emphysema Secondary to Pulmonary Tuberculosis

Spontaneous subcutaneous emphysema (SCE) is an uncommon clinical finding in pulmonary tuberculosis (TB) and can lead to diagnostic uncertainty due to its unusual presentation. It typically results from air leakage through cavitary lesions or bronchopleural fistulae, leading to the accumulation of air in subcutaneous tissues, often accompanied by pneumothorax and pneumomediastinum. We report the case of a 30-year-old male with a prior history of treated pulmonary TB who presented with fever, productive cough, progressive dyspnea, and swelling of the face, neck, and chest. Examination revealed widespread crepitus over the upper body and hypoxia requiring high-flow oxygen support. Imaging showed extensive fibrocavitatory changes in both lungs, bilateral pneumothorax, pneumomediastinum, and significant SCE. Sputum acid-fast bacilli (AFB) testing was positive (3+) for Mycobacterium tuberculosis, and Pseudomonas aeruginosa was also isolated. The patient was initially started on broad-spectrum antibiotics without improvement. On Day 4 of admission, antitubercular therapy (ATT) was initiated following microbiological confirmation. The patient showed significant clinical improvement within 72 hours of starting ATT. The SCE resolved progressively, respiratory distress diminished, and oxygen support was discontinued by Day 7. He was discharged in stable condition on Day 9 with continuation of ATT and outpatient follow-up. This case highlights the importance of considering TB in the differential diagnosis of spontaneous SCE, particularly in endemic regions. Early recognition and initiation of ATT can result in rapid clinical improvement and prevent serious complications.