Occurrence of bronchial anthracofibrosis in respiratory symptomatics with exposure to biomass fuel smoke.

INTRODUCTION: Bronchial anthracofibrosis (BAF), confirmed bronchoscopically, is characterised by bluish-black mucosal pigmentation and distortion/narrowing of the bronchus. We investigated the occurrence of BAF in respiratory symptomatics with biomass fuel smoke exposure and evaluated its clinico-radiological attributes and impact on functional status. MATERIAL AND METHODS: Of the eighty subjects evaluated, 60 consented for fiberoptic bronchoscopy (FOB). All 60 subjects also underwent chest radiography, high resolution computed tomography (HRCT) of the thorax, complete pulmonary function testing including diffusion capacity and six-minute-walk test. Information regarding cardinal respiratory symptoms and duration of biomass fuel smoke exposure was documented. FOB evaluation revealed that 24 patients had BAF (Group 1), 17 had bronchial anthracosis (Group 2) and 19 had normal appearance (Group 3). RESULTS: Group 1 patients had significantly higher biomass fuel smoke exposure (p < 0.0001), lower mean post bronchodilator FEV1/FVC values (P = 0.02) and lower walk distance (p = 0.003) with greater desaturation. On HRCT, segmental collapse and consolidation were significantly higher in Group 1 while fibrotic lesions were the predominantly seen in Groups 2 and 3. A significant inverse correlation in Group 1 was seen between exposure index, six-minute-walk distance and spirometric parameters. In Group 1, the right middle lobe (RML) bronchus was most commonly involved (15/24 [62.5%]). In Group 2, RML and left upper lobe bronchi were affected in 8/17 (47.1%) patients each. CONCLUSIONS: All patients in our study were females. Those with BAF had poorer lung functions and functional status as compared to those with anthracosis only. On imaging, multifocal bronchial narrowing was specific to BAF.    .

'Crazy-paving' pattern: an exceptional presentation of cryptogenic organising pneumonia associated with chronic obstructive pulmonary disease.

Organising pneumonia (OP) is a distinct but uncommon entity with characteristic clinicoradiological features and histological findings. When the aetiology of OP remains unknown, it is termed as cryptogenic OP (COP). COP is seen in the majority of patients with OP and usually observed in non/former smokers. A 54-year-old man, a smoker, presented with breathlessness, cough and mucoid sputum. Imaging demonstrated unilateral 'Crazy-paving' pattern in the left upper lobe and left-sided effusion. In addition, paraseptal emphysema and left lower lobe bullae along with very severe obstructive ventilatory defect and impaired diffusion suggested chronic obstructive pulmonary disease (COPD). Transbronchial biopsy was suggestive of OP. In the absence of a definite aetiology, a diagnosis of COP associated with COPD was established. COP presenting as a unilateral 'Crazy-paving' pattern is yet to be documented. To the best of our knowledge, this is the first detailed description of COP presenting as unilateral 'Crazy-paving' pattern associated with COPD.

Middle lobe syndrome: a singularly rare presentation of complicated pulmonary hydatid disease.

Imaging is crucial to the diagnosis of pulmonary hydatid disease, as it is often the first modality that raises suspicion of the disease. Middle lobe syndrome (MLS) as a presentation of this disease is a distinct rarity. A 45-year-old woman, a never-smoker, presented with cough and streaky haemoptysis. Imaging demonstrated a trapezoidal opacity with its base towards the hilum and contiguous with the right cardiac border. The reformatted sagittal view confirmed the diagnosis of MLS. Fibreoptic bronchoscopy (FOB) revealed an avascular white membranous structure wholly occluding the medial segment of the middle lobe. This was completely removed through gentle suction. Bronchial aspirate revealed hooklets of hydatid and echinococcal serology was positive. Subsequently, three cycles of albendazole were administered with remarkable clinical and radiological improvement. To the best of our knowledge, this is the first detailed description of MLS caused by pulmonary hydatidosis that was completely removed through FOB.

Bronchial anthracofibrosis with interstitial lung disease: an association yet to be highlighted.

Bronchial anthracofibrosis (BAF), an emerging pulmonary disease due to long-standing exposure to biomass fuel smoke, is predominantly seen in females from developing nations. BAF is known to be associated with tuberculosis, pneumonia, chronic obstructive pulmonary disease and lung cancer, but the association of BAF with interstitial lung disease (ILD) is rare and yet to be highlighted. A 72-year-old woman with a 30-year history of exposure to biomass fuel smoke presented with dry cough and exertional dyspnoea. Imaging demonstrated interlobular, intralobular and peribronchovascular interstitial thickening and honeycombing adjoining the subpleural regions, suggestive of the usual interstitial pneumonia pattern. A restrictive pattern with diffusion defect was noted. Fibrebronchoscopy revealed a bluish-black anthracotic pigmentation with a narrowed and distorted left upper lobe, and apical segment of left lower lobe bronchus, confirming BAF. A diagnosis of BAF with ILD was made. To the best of our knowledge, this is the first detailed description of this association.

Acute invasive pulmonary aspergillosis, shortly after occupational exposure to polluted muddy water, in a previously healthy subject.

Invasive pulmonary aspergillosis (IPA) predominantly occurs in severely neutropenic immunocompromised subjects. The occurrence of acute IPA after brief but massive exposure to Aspergillus conidia in previously healthy subjects has been documented, although only six such cases have been reported. The diagnosis was delayed in all six of the affected patients, five of whom died. We report the case of a 50-year-old HIV-negative male, a water pipeline maintenance worker, who presented with acute-onset dyspnea and fever one day after working for 2 h in a deep pit containing polluted, muddy water. Over a one-month period, his general condition deteriorated markedly, despite antibiotic therapy. Imaging showed bilateral diffuse nodules with cavitation, some of which were surrounded by ground-glass opacity suggestive of a halo sign (a hallmark of IPA). Cultures (of sputum/bronchial aspirate samples) and serology were positive for Aspergillus fumigatus. After being started on itraconazole, the patient improved. We conclude that massive exposure to Aspergillus conidia can lead to acute IPA in immunocompetent subjects.

Acute invasive pulmonary aspergillosis, shortly after occupational exposure to polluted muddy water, in a previously healthy subject / Aspergilose pulmonar invasiva aguda, logo após exposição ocupacional a água poluída barrenta, em indivíduo previamente saudável

Invasive pulmonary aspergillosis (IPA) predominantly occurs in severely neutropenic immunocompromised subjects. The occurrence of acute IPA after brief but massive exposure to Aspergillus conidia in previously healthy subjects has been documented, although only six such cases have been reported. The diagnosis was delayed in all six of the affected patients, five of whom died. We report the case of a 50-year-old HIV-negative male, a water pipeline maintenance worker, who presented with acute-onset dyspnea and fever one day after working for 2 h in a deep pit containing polluted, muddy water. Over a one-month period, his general condition deteriorated markedly, despite antibiotic therapy. Imaging showed bilateral diffuse nodules with cavitation, some of which were surrounded by ground-glass opacity suggestive of a halo sign (a hallmark of IPA). Cultures (of sputum/bronchial aspirate samples) and serology were positive for Aspergillus fumigatus. After being started on itraconazole, the patient improved. We conclude that massive exposure to Aspergillus conidia can lead to acute IPA in immunocompetent subjects.

A aspergilose pulmonar invasiva (API) ocorre predominantemente em indivíduos imunocomprometidos com neutropenia grave. A ocorrência de API aguda após exposição breve, mas maciça, a conídios de Aspergillus sp. em indivíduos previamente saudáveis já foi documentada, embora apenas seis casos tenham sido relatados. O diagnóstico foi tardio em todos os seis pacientes afetados, dos quais cinco foram a óbito. Relatamos o caso de um homem de 50 anos de idade, HIV negativo, trabalhador de manutenção de tubulação de água, que apresentou dispneia e febre de início agudo um dia após trabalhar 2 h em uma vala funda contendo água poluída e barrenta. Num período de um mês, seu estado geral se deteriorou acentuadamente, apesar da antibioticoterapia. Exames de imagem mostraram nódulos bilaterais difusos com cavitação, alguns dos quais circundados por opacidade em vidro fosco sugestiva de sinal do halo (uma característica da API). As culturas (de amostras de escarro/aspirado brônquico) e a sorologia foram positivas para Aspergillus fumigatus. Após iniciado o tratamento com itraconazol, o paciente melhorou. Concluímos que a exposição maciça a conídios de Aspergillus pode levar a API em indivíduos imunocompetentes.