An 89-year-old nonsmoker male with the past medical history of hypertension, dementia, and benign prostatic hyperplasia presented with progressive worsening of shortness of breath for 5 months and mild cough with clear white color sputum. He denied any fevers, chills, weight loss, night sweats, or loss of appetite. On physical examination, he was alert and oriented, with normal vital signs. His SpO2 was 92% while breathing ambient air. Bilateral diminished respiratory excursion and faint bibasilar wheezing were noted on chest examination, and cardiac auscultation found no murmurs or irregularities. The blood cell counts, electrolytes, and renal and liver function tests were unremarkable and QuantiFERON-Tuberculosis Gold was negative. An arterial blood gas analysis showed pH 7.45, PCO233.9 mmHg, and PO268.1 mmHg on room air. Chest radiography showed right-sided pleural effusion [Figure 1], and computed tomography of the chest showed bilateral pleural effusion right greater than left, with atelectasis of RLL [Figure 2]. The patient underwent diagnostic and therapeutic right-sided pigtail catheter placement which drained serous exudative pleural fluid on Light's criteria with lymphocytic predominance. Pleural cultures and cytology were negative. Postpleural fluid drainage and repeated chest imaging showed right-sided unexpandable lung with pneumothorax ex vacuo and possible endobronchial lesion in the right middle lobe (RML) bronchus [Figures 3 and 4]. Subsequently, bronchoscopy was performed which showed narrowed RML bronchi with significant mucosal edema and a round smooth-bordered 3.0 cm endobronchial lesion at RLL bronchi not allowing the bronchoscope to pass beyond the lesion. Endobronchial biopsies, bronchoalveolar lavage, and cytological brushing were performed. RML biopsy showed chronic bronchitis and was negative for malignancy or granulomatous inflammation. RLL biopsy with Verhoeff's elastic staining showed plexus of elastic fibers parallel to basement membrane [Figure 5]. Immunoperoxidase staining on RLL showed the presence of elastic tissue as fibrillar amphophilic material which was centered around blood capillary vessels consistent with the diagnosis of bronchial elastosis [Figure 6]. The first cytology from pleural fluid was negative, and because of the patient's wishes, no further staging and intervention including bronchoscopy removal or surgical resection were performed. After physiological and clinical improvement, the patient was discharged in a stable condition to a long-term care facility.
Computed tomography of the chest postpigtail catheter drainage confirming right-sided unexpandable lung (red arrow) with possible endobronchial lesion in the right middle lobe bronchus (blue arrow).