Sripavatakul and Foocharoen Journal of Medical Case Reports 2011, 5:309 http://www.jmedicalcasereports.com/content/5/1/309 Page 4 of 6 Figure 5 Chest radiography reveals pneumothorax of right lung. immediately. Oral fluconazole (400 mg per day) was prescribed after the presence of Cryptococcus was con- firmed (three days after pneumothorax) and continued for six months. The fever, pleuritic chest pain and cough symptoms improved and the lung was re- expanded the third day after chest tube insertion with- out any complications. The oxygen line was removed seven days after treatment. A chest radiograph indicated improvement of pulmonary infiltration two weeks after Figure 6 Chest radiography four weeks after treatment reveals improvement of pneumothorax and pulmonary infiltration. treatment (Figure 6). Four weeks after treatment the serum cryptococcal antigen test and hemoculture for Cryptococci were negative. No recurrent pneumothorax was detected after anti-fungal therapy was discontinued. Discussion Spontaneous pneumothorax can be a complication of infection from invasive necrotizing organisms such as anaerobic bacteria [5], Staphylococcus [6], Klebsiella pneumoniae [7], tuberculosis [8,9], aspergillosis [10,11], Pneumocystis jiroveci [12], Scedosporium apiospermum mycetoma [13] or be associated with pre-existing lung disease such as chronic obstructive pulmonary disease [5], status asthmaticus [5], cystic fibrosis [5], cancer [14], thoracic endometriosis [15] or connective tissue disease [5]. All of the above would be termed secondary spontaneous pneumothorax (SSP). SSP in rheumatic diseases have been reported in SSC [2,3], polymyositis [16], mixed connective tissue disease [17], systemic lupus erythematosus [18,19], Wegener’s granulomatosis [20,21], relapsing polychondritis [22], ankylosing spondylitis [23], and rheumatoid arthritis [24], particularly in persons with a pre-existing lung dis- ease associated with an underlying connective tissue dis- ease. Spontaneous pneumothorax in SSC has been reported in patients with sub-pleural blebs or lung cysts, which are perhaps due to abnormal collagen in the pul- monary tissue as a result of SSC [2,3,25]. An enlarged sub-pleural cyst, particularly > 1 cm, might be a risk for spontaneous pneumothorax in patients with SSC [2]. Our patient had pre-existing pulmonary fibrosis related to his underlying SSC. A HRCT chest scan revealed only sub-pleural emphysema and he developed spontaneous pneumothorax after pulmonary infection. We conclude that, even though sub-pleural blebs occur in SSC in association with spontaneous pneumothorax, infection can exacerbate symptoms in patients with sub- pleural emphysema, thereby triggering spontaneous pneumothorax. Spontaneous pneumothorax related to cryptococcal pneumonia has been reported, but mostly in underly- ing acquired immunodeficiency syndrome (AIDS) [26]. There is one report in a healthy young woman [27]. There are no reports of spontaneous pneumothorax related to cryptococcal pneumonia in persons with SSC. The pathophysiology of spontaneous pneu- mothorax could be a result of lung tissue necrosis due to infection [5], and the pulmonary complications of SSC could be a predisposing factor for pneumothorax in cases where there is a thinning sub-pleural bleb or bullae. The objectives of treatment in both primary sponta- neous pneumothorax (PSP) and SSP are to remove air from the pleural space and to prevent recurrent