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A 60-year-old man with a history of benign prostate hyperplasia was referred to our clinic for evaluation of persistent left lower lobe chest X-ray (CXR) changes and symptoms suggestive of recurrent chest infection that did not improve with antibiotic therapy. On history, the patient vividly recalled an episode of violent coughing 3 months ago while eating peanuts. Thereafter, he reported daily cough with clear productive sputum and breathlessness on heavy exertion. The patient is a lifelong non-smoker and reported no other infective or cardiac symptoms, or relevant environmental exposures. On examination, the patient was not dyspnoeic. Temperature was 37.2°C, respiratory rate 12 breaths/min and room air oxygen saturation 97%. Chest auscultation revealed left basal coarse crackles which did not clear on coughing. The remainder of the clinical examination was normal.
Full blood count, C reactive protein, urea and electrolytes, and liver function test were normal. To further evaluate the CXR changes, a chest CT was performed. This showed an endobronchial lesion in the proximal left lower lobe bronchus associated with distal bronchiectasis, peribronchial consolidation and tree-in-bud opacities (figure 1). Bronchoscopy identified a peanut firmly wedged in the left lower lobe bronchus with surrounding mucosa erythema and oedema (figure 2). This was successfully extracted with a rat tooth forceps and washout of copious pus distally was performed. The patient’s symptoms promptly resolved and chest CT 2 months later showed marked improvement in the previously identified abnormalities, with residual smooth bronchial dilation and scattered ground glass (figure 1).
Bronchiectasis is classically defined as a clinical syndrome of cough, sputum production and bronchial infection, and radiologically by abnormally widened airways, lack of tapering and/or visibility of the airways in the peripheral of the lung.1 Bronchiectasis may be caused by infectious (bacterial, viral, mycobacterial) and non-infectious aetiologies including airway obstruction (foreign body), dysfunctional immune system (hypogammaglobulinaemia, allergic bronchopulmonary aspergillosis), connective tissue diseases (rheumatoid arthritis) and congenital disorders (cystic fibrosis, William-Campbell syndrome). Regardless of the cause, a vicious cycle of chronic infection, airway inflammation, structural destruction and impaired mucociliary clearance perpetuates the disease.2 Identifying the cause may direct management as shown in this case.
Reversible bronchiectasis describes a form of bronchiectasis whereby bronchial dilation is reversible following control of the inciting trigger. This phenomenon has been reported in acute infections such as pneumonia, and in limited cases involving foreign body aspiration, and may take between 1 and 6 months to resolve.3 We believe that the prompt control of infection and inflammation (by removal of the foreign body) before the destruction of elastic tissue and bronchial musculature was crucial to the reversibility and prevention of subsequent irreversible bronchial dilation.4 In line with the British Thoracic Society guideline,5 we believe that all patients with localised bronchiectasis in the absence of a clear aetiology should undergo bronchoscopy to exclude endobronchial pathology. We also highlight the importance of exercising caution when making the diagnosis of bronchiectasis especially in those with acute symptoms, and the need for follow-up imaging to monitor for resolution.
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Contributors CTF and JH were involved in the conceptualisation, data curation, writing, editing and reviewing of the manuscript. SK has contributed to the data curation, analysis, writing, editing and reviewing of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.