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Case presentation
A 94-year-old female patient was referred to the emergency department of our hospital for cough productive of purulent sputum and recurrent episodes of haemoptysis. She was a mild, former smoker. Her medical history was notable for a left-sided pleuropulmonary infection treated for months with antibiotics at the age of 2 years, and for recurrent respiratory infections occurring ever since. Chest CT revealed multiple abnormalities of the left lung consisting of a marked volume loss; diffuse bronchiectasis prevailing in the upper lobe, where a large airway consolidation was also evident; and multiple centrilobular nodules of variable sizes (figure 1A,B). Furthermore, a reduction of the lumen of the left main stem bronchus associated with possible fractures of some cartilage rings was noticed (figure 1C, arrow). Xpert Mycobacterium tuberculosis/resistance to rifampicin (MTB/RIF) and subsequently culture of the sputum were positive for a drug-susceptible Mycobacterium tuberculosis complex strain. A 9-month antitubercular treatment led to the rapid remission of symptoms and to a marked radiological improvement. However, 1 month after stopping the treatment, she was admitted again to hospital because of shortness of breath, productive cough and haemoptysis. A new chest CT confirmed the improvement of the parenchymal abnormalities (figure 1D,E) but showed an increase in the number of damaged cartilage rings, which extended up to the lobar bronchi (figure 1F, arrows). Bronchoscopy demonstrated the fracture of several consecutive cartilage rings involving the left main stem bronchus in its entire length (figure 2A–C, arrows). The cartilage damage was severe enough to cause the complete collapse of the airway in the distal third of the main stem bronchus and to prevent the lobar bronchi from being explored despite the use of a 3.5 mm sized video-bronchoscope (figure 2C, online supplementary video). Xpert MTB/RIF and culture of the bronchial washing were negative. Haemoptysis subsided spontaneously.
Supplementary video
Rupture and protrusion of the airway cartilage rings, also known as fish-scale airway degeneration, is an exceedingly rare and poorly known complication of pulmonary tuberculosis.1 2 The case presented herein is the third microbiologically confirmed case published in the medical literature, to our knowledge.1 2 Interestingly, all of the patients described up to now were female, and all of them underwent resolution of the clinical and microbiological abnormalities, but the anti-TB treatment had no effect whatsoever on the airway cartilage damage.1 2
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Footnotes
Contributors RT contributed to the conception and design, as well as writing of the manuscript. MF, DP, VL and FN contributed to the data acquisition, writing of the manuscript and its revision for important intellectual content.
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.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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