Of the many body systems adversely affected by severe anorexia nervosa (AN), the pulmonary system is relatively spared. However, in the face of severe malnutrition of AN, the lung may undergo architectural changes that adversely affect its integrity and healing capacity. We report herein a case of a pneumothorax in a patient with severe AN, in which standard approaches to manage the pneumothorax were unsuccessful. Despite prolonged tube thoracostomy drainage, and subsequent thoracoscopic pleuredesis, the patient continued to have an air leak and non-resolution of her pneumothorax. We review the literature and discuss alternative approaches in this patient population.