A 28-year-old male presented to the pulmonology outpatient department with recurrent respiratory tract infections and a persistent productive cough for 14 years associated with exertional dyspnea, chest pain and an occasional wheeze. He denied having any constitutional symptoms, hemoptysis, paroxysmal nocturnal dyspnea, palpitations, orthopnea or lower limb swelling. Additionally, he denied any rash, joint pains or joint swellings. Review of other symptoms was similarly unremarkable.
His past medical history was significant for being treated for tuberculosis (TB) twice in 2018 and 2019 based on chest radiograph abnormalities. Microscopy for Mycobacterium tuberculosis and molecular testing of sputum specimens were negative on both occasions. The family history revealed his mother and a sister having similar histories of long-standing productive cough of unclear aetiology. He worked at a road construction site for the past 4 years with exposure to dust and cement and admitted to a 5-pack year smoking history.
Clinical findings: on pulmonary auscultation, there were bilateral squeaky breath sounds with wheezes that were more prominent anteriorly. The rest of his physical examination was unremarkable.
Diagnostic assessment: his baseline laboratory investigations (Table 1) revealed a normal full blood count and white cell differential cell count, as well as normal renal function and normal liver enzymes. His serum immunoglobulin E levels were increased at approximately fifteen times the upper limit of normal levels. Aspergillus fumigatus serology and alpha-1 antitrypsin levels were both within normal limits. A human immunodeficiency virus (HIV) test was negative. His bronchial washings were sent for bacterial and fungal cultures, as well as testing for acid-fast bacilli and MTB/RIF-GenXpert . These results were negative.
The electrocardiogram and echocardiography were normal. Spirometry showed an obstructive pattern with significant bronchodilator responsiveness (Table 2). High-resolution chest computed tomography (CT) revealed a dilated trachea (31mm, measured 2cm above the aortic arch) with diverticula, as well as dilation of the main bronchi (left 24mm and right 21mm) with extensive bilateral cystic bronchiectasis (Figure 1(A,B)). Bronchoscopy revealed normal symmetrical vocal cords with a dilated trachea and main bronchi with multiple diverticula and pouches containing pooled secretions (Figure 1(C,D)).
Therapeutic intervention: the patient was started on inhaled fluticasone/formoterol as well as chest physiotherapy. He was also advised on smoking cessation and to switch to an office-based job to limit his exposure to air pollutants.
Follow-up and outcomes: the patient reported an improvement in his symptoms and is currently being followed up regularly at the Pulmonology Outpatient Clinic.
Patient perspective: "I am glad I finally know the reason for my medical condition. Previously I would just get treated for TB despite all my tests being negative and this was quite frustrating. I now try to avoid things that make my condition worse and live a healthier lifestyle. I now have an office desk job and have quit smoking. In addition, I have started chest physiotherapy and regularly take my prescribed inhaler which has markedly improved my symptoms".
Informed consent: the patient provided written informed consent for this case and the images from his diagnostic tests to be written up and published.
chest CT showing a dilated trachea (>3cm), dilated main bronchi, and ,cystic bronchiectasis, mainly in the lower lobes.