immune reconstitution reactions are rare in pulmonary tuberculosis , especially in non - immunocompromised patients . we present a 21 year old immunocompetent patient that developed bilateral pneumothoraces and respiratory failure as a result of immune reconstitution syndrome during treatment for pulmonary tuberculosis . a 21-year - old male presented with fever , cough , anorexia and weight loss of 2 months duration . he was a student , did not smoke and did not report alcohol or substance abuse . he reported exposure to pulmonary tuberculosis as a caregiver to a sibling 18 months prior to this episode ; his sister recovered completely with 6 months of antituberculosis treatment . tuberculin testing or isoniazid prophylaxis was not offered to the index patient according to current practice in india . he did not raise pets and had stayed alone in a hostel for the last 4 months . chest radiographs showed bilateral infiltrates and computed tomography [ ct , figure 1 ] showed findings suggestive of extensive pulmonary tuberculosis . tuberculin skin testing was negative ( 6 mm with 5 tu at 72 h ) . neelsen 's stain and supervised daily four - drug antituberculosis treatment ( isoniazid 200 mg , rifampicin 450 mg , pyrazinamide 1000 mg , ethambutol 600 mg , pyridoxine 20 mg ; weight 40 kg ) was initiated and sputum cultures and drug susceptibility for mycobacterium tuberculosis by multiple growth indicator technique ( mgit ) was requested . nutrition counseling and four doses of 2-weekly vitamin d 100,000 i.u were administered as per unit 's protocol . he presented with fever , worsening breathlessness , weight loss and chest pain 4 weeks after starting treatment . on examination he was afebrile , normotensive with respiratory rate of 40 breaths / min and pulse rate of 130 beats / min . kg / m , normal 1925 kg / m ) . respiratory examination showed reduced right - sided movements and breath sound intensity with coarse left - sided crackles . chest radiography [ figure 1 , left ] confirmed the diagnosis of right - sided pneumothorax with increased bilateral infiltrates . he was admitted to the intensive care unit ( icu ) with appropriate respiratory isolation ; intercostal chest drain was inserted on the right side . there was evidence of air - leak ( cerfolio e ) from the right lung with minimal subcutaneous emphysema . noninvasive positive pressure ventilation ( nippv ) was started ; no worsening of air - leak was noted . repeat sputum smears showed downgrading of smears with scanty acid - fast bacilli by zeihl - neelsen 's stain . repeat ct - chest [ figure 2 ] showed increase in cavitation , consolidation and ground - glass opacities bilaterally . fasting blood glucose was 87 mg / dl and human immunodeficiency virus elisa was negative and there was no cd4 lymphocytopenia . arterial blood gas analysis showed corrected hypoxemia and respiratory alkalosis ( ph 7.42 , po2 78 mm hg on fio20.4 , pco228 mm hg , hco322 meq / l ) . he was continued on four - drug antituberculosis treatment ; further doses of vitamin d were not administered . he developed contralateral pneumothorax on the 2 day of admission and worsened hypoxemia needing mechanical ventilation . urgent left intercostal tube drainage was performed and air - leak ( cerfolio i ) was noticed on the left side also . high - resolution computed tomography of the chest at diagnosis showing a large right upper lobe cavity ( right ) and extensive random nodules in bilateral lower lobes ( right ) high - resolution computed tomography of the chest after 1-month of treatment showing increase in cavitation and new - onset consolidation and ground glass appearance bilaterally in the upper lobes ; bilateral pneumothoraces and intercostal drains are also seen laboratory values during icu admission of index patient the differential diagnosis of a new or worsening finding in a patient with tuberculosis on treatment includes wrong diagnosis ( if diagnosis not microbiologically confirmed ) , an improper regimen , noncompliance , drug - resistant m. tuberculosis , nontuberculosis - mycobacterial disease ( hiv - aids ) , super - infection with bacteria or pneumocystis jerovicii , drug hypersensitivity and immune reconstitution . given the reported rarity of immune reconstitution in hiv - negative pulmonary tuberculosis , we measured cytokines ( bioplex cytokine assay kit ; biorad ) and t cell subsets and activation markers by flow cytometry [ facs cantou ii , beckton dickinson , table 1 ] . the strong interferon - g responses to rd1 antigens ( quantiferon - gold ) favor the diagnosis of immune reconstitution syndrome ( iris ) . immune reconstitution is defined as development of new lesions or clinical and/or radiological worsening of preexisting ( tuberculosis ) lesions not attributable to the normal course of disease in a patient ( with tuberculosis ) initially improving on ( antituberculosis ) treatment . immune reconstitution is associated with a wide spectrum of pathogens , most commonly mycobacteria , herpes , and deep fungal infections . it has been reported to complicate treatment in 836% of hiv - infected patients with tuberculosis . while less is known about immune reconstitution in pulmonary tuberculosis in non - hiv settings , it has been reported in up to 2.4% of patients . immune reconstitution in non - hiv setting occurs more commonly in extra - pulmonary tuberculosis and in patients with anemia , malnutrition , hypoalbuminemia and lymphocytopenia at baseline . immune reconstitution occurs at varied intervals with a median of 11 - 46 days after initiation of antituberculosis therapy . radiological findings suggestive of immune reconstitution in pulmonary tuberculosis includes new or worsening infiltrates and endobronchial lesions , new pleural effusions , new / worsening cavitation and acute respiratory syndrome . findings suggestive of immune reconstitution in extra - pulmonary tuberculosis include new or enlarging neurological lesions , new or enlarging soft tissue masses and pleural effusions . paradoxical reactions have been attributed to immunological causes such as the strengthening of the host 's delayed hypersensitivity response , a decrease in suppressor mechanisms as a consequence of increased exposure to mycobacterial antigens secondary to mycobactericidal chemotherapy . recent consensus statements of hiv - related immune reconstitution have stressed that the diagnosis should be made on clinical grounds and that viral load and cd4 assays are not routinely needed . treatment of immune reconstitution is controversial ; treatment varies from observation , analgesics , nonsteroidal antiinflammatory drugs and steroids depending on the severity of the clinical syndrome . surgical drainage may be necessary in extra - pulmonary tuberculosis . in scenarios with high - risk for immune reconstitution , a clinical visit must be scheduled and patients counseled appropriately . in the index patient , in view of isolation of pan - sensitive m. tuberculosis , good compliance , down - graded smears and negative cultures with therapy and strongly suggestive serological responses , a diagnosis of iris was considered and 20 mg prednisolone was administered daily . he improved symptomatically with resolution of fever and constitutional symptoms , weight gain and resolution of right - sided alveolo - pleural fistula . he continued to have left - sided alveolo - pleural fistula requiring thoracotomy and stapling at 4 months of treatment [ figure 3 , right ] . composite mage of chest radiographs with left , at initial pneumothorax and respiratory failure showing bilateral extensive upper lobe infiltrates and right pneumothorax with intercostals drain . the image on the right at end of treatment shows expanded bilateral lungs with residual fibrosis in the right upper zone