A 75-year-old woman, farmer, nonsmoker from a rural area; with no history of TB, hay fever, eczema, food allergy or cardiovascular diseases. There is no history of exposure to asbestos or any other industrial dust except wood smoke. The latter was as the result of years of burning wood used for domestic chores and sold oak charcoals. There was no family history of TB or any other chronic lung diseases.
At presentation to respiratory clinic she described a two years history of wheeze and three months history of progressive breathlessness, productive cough, night sweating and some weight loss. Examination confirmed wide spread expiratory polyphonic wheeze. She had been previously treated with inhaled bronchodilators that conferred only modest response.
The patient underwent a number of investigations including blood biochemistry, sputum examination for culture and sensitivity and acid-fast bacilli (AFB), echocardiogram, CT scan of chest, spirometry and bronchoscopy. We report the positive results as follow:
Erythrocyte Sedimentation Rate (ESR) of 88mm/h and CT scan showed narrowing of the right middle lobe bronchus with partial collapse of the right middle lobe and ipsilateral hilar lymph node enlargement (Fig. 1). Spirometry with reversibility confirmed fixed airflow obstruction: FVC 1.87 L (80% of predicated), FEV1 1.14 L (62% of predicated), FEV1/FVC was 61% of predicated; FEF 25-75 was 42% of predicated. Bronchoscopy revealed patchy black pigmentation of bronchial mucosa and significant bronchial narrowing of right middle lobe bronchus (Fig. 2, Fig. 3, Fig. 4), endobronchial washing was strongly stained for AFB. Bronco-alveolar lavage showed none specific inflammatory cells but no cancer cells.