A 36-year-old female patient was admitted to our hospital due to chronic cough, expectoration, chest tightness and wheezing. She is a never smoker. She had experienced chronic sinusitis since the age of 12 and started experiencing cough and purulent sputum at the age of 20. The symptoms progressively worsened, presenting with exertional dyspnea and constant wheezing. At the age of 25, the patient underwent "thoracotomy drainage and biopsy" in the local hospital due to "empyema and pleural effusion." Physical examination on admission revealed diffuse expiratory wheezes and coarse crackles in both lungs. Pulmonary function test showed that the ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV1/FVC) was 43.39% (Table 1). Blood gas analysis showed hypoxemia with an oxygen partial pressure (PaO2) of 62 mmHg and oxygenation index of 155 mmHg. Chest high-resolution computed tomography (HRCT) scan showed well-defined multiple centrilobular nodules and diffuse tree-in-bud pattern (Figure 1A). No obvious abnormalities were found in routine blood tests, procalcitonin, sputum smear microscopy, sputum culture, tuberculosis bacili gamma interferon release test, rheumatoid factors, humoral immunity, connective tissue related antibodies, anti-neutrophil cytoplasmic antibody, etc. On the first admission, the patient's symptoms improved after symptomatic treatment such as antitussive, expectorant and antiasthmatic treatment and discharged from the hospital automatically.
However, the patient presented with the above symptoms repeatedly and was hospitalized in our hospital again after 1 month. On this admission, we performed further investigations on this patient. Paranasal sinus CT showed bilateral maxillary sinus inflammation (Figure 2A, 2B). Cold agglutinin level was in the normal range. A diagnosis of diffuse panbronchiolitis was made given the symptoms, signs, history of sinusitis, radiological, pulmonary function and laboratory findings. In this hospitalization, we treated the patient with azithromycin (500 mg per day), and the respiratory symptoms of the patient were obviously improved. However, dyspnea symptoms of the case 1 were not well controlled, so we treated the patient with prednisone acetate for 12 months. The dose was gradually reduced from 30 mg to 10 mg per day and finally stopped.
Since then, the patient has been followed up at our hospital for 2 years, sometimes hospitalized for deterioration of her condition. Sixteen months after the definite diagnosis, the patient was hospitalized again in our hospital for cough, expectoration and dyspnea. Chest CT showed a small nodule at the upper tip of the right lung (Figure 3D). Sputum culture showed a small amount of Pseudomonas aeruginosa growth (++). Fiberoptic bronchoscopy revealed abundant purulent secretions in the left and right main bronchi and all levels of bronchi (Figure 4). Bronchoalveolar lavage fluid culture showed that Pseudomonas aeruginosa was 300 colony-forming units per milliliter (CFU/ml). The second bronchoscope lavage fluid smear revealed 1 root of acid-fast bacilli/300 visual field, and the culture showed a small amount of fusarium. Mycobacterium tuberculosis complex group DNA was positive. The patient was diagnosed as secondary pulmonary tuberculosis and received anti-tuberculosis treatment with isoniazid, rifapentine, ethambutol and moxifloxacin. Since then, the patient has received anti-tuberculosis treatment for up to 12 months. The patient's condition gradually improved and the nodule in the right lung showed significant shrinkage (Figure 3E, 3F) after anti-tuberculosis treatment.