A 59-year-old male smoker (30 pack-years) was investigated for productive cough of 1 month. He had a past history of pulmonary tuberculosis (25 years ago; unavailable medical records) and mentioned occasional episodes of dry cough every year for the last 3 years. His family and occupational history were not significant. One month earlier, he had been diagnosed with pulmonary tuberculosis at another institution, but his sputum smear and culture were negative for acid-fast bacilli at the time of admission. His physical examination was unremarkable apart from the respiratory rate of 21/min. Laboratory studies revealed a white blood cell count of 5.54 x 109/l, platelet count of 104 x 109/l, neutrophils 72.6%, and an erythrocyte sedimentation rate of 21 mm/h. Liver and renal function tests were normal except for a high uric acid level (937.9 mumol/l). He tested negative for HIV and HBV antibodies. CT demonstrated increased density in the lateral segment of the right middle lobe, but was otherwise normal. The bronchial provocation test with methacholine was unremarkable. Bronchoscopy revealed an uneven layer of inflamed mucosa. Histopathological examination showed bronchial mucosal inflammation with squamous metaplasia but serum bone morphogenetic protein 2 was negative. An antimycobacterial combination regime (rifampicin + isoniazid + pyrizinamide + ethambutol) was initiated with a provisional diagnosis of endobronchial tuberculosis. The patient experienced relief of symptoms and was discharged, with follow-up scheduled after 1 month. At follow-up, the patient reported worsening cough and occasional blood-tinged sputum. CT revealed an increased density in the cartilage ring surrounding the trachea (fig. 1a). Bronchoscopy showed tracheal stenosis with white, hard spicules (fig. 1b, c). Histopathology confirmed the presence of cartilaginous and osseous nodules in the bronchial submucosa with a moderate degree of squamous metaplasia (fig. 1d). An interdepartmental consultation recommended a temporary discontinuation of the antimycobacterial combination regime (to verify that his airway changes were not drug-induced). Within 1 week of discontinuation, his symptoms eased and he had a better respiratory status. The patient was managed with bronchoscopic nodule removal and laser ablation. At the 4-month follow-up, radiographic findings were negative and the patient reported progressive relief in his symptoms.