A 33-year-old male presented with progressive breathlessness and dry cough since the last 5 months and right sided pleuritic chest pain for 10 days. Patient was diagnosed elsewhere as miliary tuberculosis and was under antitubercular treatment (ATT) for four months. He was not a smoker. He worked as a bore-well driller for the past 10 years.
Blood hemogram and renal and liver functions were normal. Admission chest radiograph showed bilateral, diffuse, well-defined large rounded nodular opacities with right secondary spontaneous pneumothorax (Figure 1).
Patient was managed with tube thoracostomy, supplemental oxygen, and analgesics. After three days patient complained of acute onset chest pain on left hemithorax and dyspnoea.
Chest radiograph revealed a new pneumothorax on left side for which immediate chest tube was placed. Subsequently, patient had symptomatic relief. Fibre optic bronchoscopy revealed normal airway. Bronchoalveolar lavage cytology showed only benign bronchial epithelial cells and smear and culture for Mycobacterium tuberculosis were negative. The diagnosis of military tuberculosis was questionable in view of larger size and nonresolution of nodules although four months of ATT and silicosis was more probable, considering his occupation. Hence, percutaneous biopsy of right lung was done that yielded a tiny tissue and showed only lymphoplasmacytic infiltrates. ATT was stopped and he was discharged after bilateral pleurodesis. Six months later he was brought to emergency with signs of severe respiratory failure. His condition deteriorated faster and despite adequate measures, he sustained a cardiopulmonary arrest and succumbed.
Limited autopsy was done. Postmortem biopsy of bilateral lungs and liver was done. H and E sections of bilateral lungs revealed multiple collagenous nodules, some of which coalesced to form larger nodules (Figures 2(a) and 2(b)). The periphery of the nodules contained dust laden macrophages and inflammatory cells, predominantly lymphocytes (Figure 2(c)). There were no granulomas; acid fast staining was negative. Under polarized light microscopy, lung tissue showed white spots which represented silica crystals (Figure 2(d)).