We report a case of a 49 year old male, never smoker. He was homeless, born in Romania, and had been working as a smith.
He had a clinical history of fatty liver disease (FLD) and renal lithiasis. He reported a history of wheezing since childhood, with non-productive cough, diagnosed at different stages as asthma. He had no family history of respiratory diseases, including tuberculosis (TB), or asthma and atopy. He was admitted to our Respiratory Unit with suspected pulmonary tuberculosis and with symptoms characterized by a low-grade fever with profuse sweating combined with productive cough of purulent sputum, dyspnea, wheezing, and chest pain. At diagnosis the patient showed a severe obstructive ventilatory deficit, not reversible after inhalation of short acting beta 2 agonists. A Chest X-Ray prescribed by his general practitioner showed diffuse interstitial thickening without parenchymal consolidation. He was treated with a broad-spectrum antibiotic but the symptoms persisted for a few weeks. Chest X-ray didn't show any parenchymal consolidation, whilst a High Resolution CT scan (HRCT) showed the presence of ground-glass opacity in the anterior segment of the right upper lobe, of suspected tubercular origin (Fig. 1).
Physical examination of the chest was negative, with no superficial palpable lymphadenopathy. During hospitalization in our department of Respiratory Disease, an antibiotic therapy with ceftriaxone was established. Blood chemistry tests did not show any alteration of inflammatory indices. Sputum culture was negative for non specific flora, fungi and Mycobacterium tuberculosis. Serological tests were also negative for Mycoplasma pneumoniae, Chlamydiae, and Pneumotropic Viruses. No urinary antigen for Legionella or Pneumococcal infection was found.
However, the patient tested positive at Quantiferon-TB and Tuberculin Skin Tests.
A Fibrobronchoscopy finally revealed the presence of mucosal irregularities spread throughout the tracheobronchial system up to the segmental bronchi entrance, prevailing in the antero-lateral wall of the trachea and sparing the membranous pars, where a biopsy was performed (Figs. 2 and 3).
The involvement of the segmental bronchi was also highlighted by HRCT (Fig. 4).
Histological examination reported a mucosal tissue edged by a metaplastic epithelium, with underlying nodules of osseouscartilaginous nature, consistent with Tracheobronchopathia Osteochondroplastica (Fig. 5).
Microbiological tests of Bronchoalveolar Lavage fluid were negative for Mycobacterium tuberculosis and also revealed an infection by Pseudomonas Aeruginosa, with bacterial load of one-million CFU / ml. Following an antibiogram, treatment with Amikacin was established, leading to a clinical and CT scan improvement.
HRCT showed irregularity in main bronchi.