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