A nine-month-old female presented with one-week history of cough, catarrh, and fever at a referral hospital where she was admitted and treated for pneumonia. On discharge after two weeks of treatment, signs of respiratory distress persisted. Recurrent and worsening dyspnea was observed over a two-month period with repeated admissions. When an ordered chest X-ray showed left upper lobe consolidation and collapse, patient was started on anti-Koch's therapy. Mantoux and erythrocyte sedimentation rate test results were 5 mm and 65 mm/hr, respectively, while tests for HIV I and II were negative. She had no history of contact with anyone with chronic cough or tuberculosis and vaccinations were up to date. There was no family history of asthma or atopy, but history of poor weight gain was present. Echocardiography ordered on account of persistent dyspnea showed a small secundum atrial septal defect which subsequently closed after 6 months.
Following 12 months of anti-Koch's therapy, an evaluation at the referral hospital revealed respiratory distress and persistent poor weight gain with weight of 8.5 kg at two years. Chest auscultation revealed widespread rhonchi and crepitations. There was no cyanosis and a repeat chest X-ray showed a hyperinflated right lung field with left upper lobe collapse and left mediastinal shift (Figure 1).
Patient was referred to our hospital for further management. The anti-Koch's therapy was discontinued and other diagnoses such as bronchial asthma, foreign body aspiration, or congenital lung malformation were entertained. The cardiothoracic surgical unit (CTSU) was involved in the management and a requested chest CT scan showed collapse consolidation of the left upper lobe with extensive air bronchogram and compensatory hyperinflation of the right upper lobe (Figure 2). A decision to do a lobectomy was taken by the CTSU, and, at 2 years of age, she underwent left posterolateral thoracotomy and left upper lobectomy. Findings at surgery were a collapsed nodular left upper lobe, left hilar and perihilar lymphadenopathy, and healthy-looking hyperinflated left lower lobe. Histology revealed dense inflammatory infiltrates composed of lymphocytes, plasma cells, and few eosinophils within the bronchiolar walls, peribronchiolar soft tissue, and adjoining interstitium. The lymphoid cells were seen forming lymphoid follicles with pale germinal centres predominantly around the bronchi and bronchioles. Some of the bronchioles contained inflammatory debris, and plugs of granulation tissue composed of fibroblasts within a myxoid stroma were seen within the bronchiolar lumens, alveolar ducts, and associated alveolar spaces (Figure 3). Areas of haemorrhage were also seen. A diagnosis of follicular bronchiolitis was made. Postoperative period was uneventful and she was discharged home with no complications. She remains symptom-free a year after the surgery and currently weighs 12 kg at 3 years.