Sripavatakul and Foocharoen Journal of Medical Case Reports 2011, 5:309 http://www.jmedicalcasereports.com/content/5/1/309 Page 5 of 6 pneumothorax. Importantly, recurrence is higher and the treatment more difficult in SSP than in PSP [28]; there- fore, the management in SSP needs to be more aggres- sive. However, it is more difficult to make observations without any hospital-based treatment, as often occurs among patients with PSP as opposed to those with SSP, and there is higher morbidity and mortality among the latter [29]. Moreover, because the chest symptoms in SSP are out of proportion with the degree of pneumothorax [30], the intervention must be prompt in those who can- not tolerate pneumothorax even if there is only a low volume of leakage into the pleural space. As for the patient with symptomatic SSP, the treatment should include oxygen supplementation to correct any arterial hypoxemia and air drainage [29]. The treatment options of air drainage in SSP depend on the patient’s condition and the size of the air leak into the pleural space. Our treatment of pneumothorax in daily practice fol- lows The British Thoracic Society (BTS) Pneumothorax Guideline [29]. Accordingly, aspiration can be per- formed with a 16-18G canula for patients with SSP if the size of the air leakage into pleural space is between 1-2 cm, whereas a chest tube drainage should be inserted if the size is > 2 cm [29]. Our patient presented with severe chest symptoms with hypoxemia and air leakage into pleural space > 2 cm [29], thus there was no doubt about the treatment option. Chest tube drai- nage and oxygen therapy were immediately performed on our patient. As per the BTS guideline, neither pleur- odesis nor surgical strategy was performed on our patient because the lung was re-expanded, the air leak was resolved and there was no recurrence of the pneu- mothorax (after chest tube drainage). In most cases, lung re-expansion will lead to rapid recovery; however, re-expansion may be delayed in a patient with SSP [31] or even in SSC [3]. Pneumothorax has been known to recur in cases of SSC [2,25], and so pleurodesis will be the final treatment in most cases of SSC. Slow lung re-expansion and recurrent pneu- mothorax in SSC may be explained by poor lung com- pliance, multiple sub-pleural cysts and pleural- thickening and fibrosis [2,3]. In contrast to previous reports, our patient had full lung re-expansion within three days of chest tube inser- tion and anti-fungal therapy. The rapid recovery of the lung after re-expansion might be related to early anti- fungal treatment and early chest tube drainage. The prognosis of lung re-expansion in SSP due to infection might be better than pneumothorax due to ruptured sub-pleural bleb in a patient with underlying SSC. In general, pleural effusion will not be detected in the ipsilateral lung of pneumothorax because the pressure in the pleural space will obscure the hydrostatic pres- sure of the interstitial fluid and there is, therefore, no movement of interstitial fluid into the pleural space [5]. Our patient had pleural fluid after chest tube insertion and the specific cause of pneumothorax came from pleural fluid analysis. Therefore pleural fluid can be a sign of a pre-existing pulmonary infection in cases of spontaneous pneumothorax. Conclusions Infection can exacerbate symptoms in a patient with sys- temic sclerosis with sub-pleural emphysema, thereby trig- gering spontaneous pneumothorax, even when minimal sub-pleural emphysema is detected. Pleural fluid–present but not initially seen because of the pneumothorax– could be a clue to a pre-existing pulmonary infection. Consent Written informed consent was obtained from our patient for the publication of this case report and any accompa- nying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Acknowledgements The authors thank the Department of Medicine and the Faculty of Medicine for their support on the approval of this manuscript, and Mr Bryan Roderick Hamman and Mrs Janice Loewen-Hamman for assistance with the English- language presentation of the manuscript. Our patient was admitted under the care of a rheumatologist and was followed up in an out-patient scleroderma clinic. Authors’ contributions All authors reviewed and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 14 August 2010 Accepted: 13 July 2011 Published: 13 July 2011 References 1. Ostojić P, Damjanov N: Different clinical features in patients with limited and diffuse cutaneous systemic sclerosis. 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