A 54 -Year-Old Man with Cough and Dyspnea

WHAT IS YOUR DIAGNOSIS? A 54-year-old male, farmer with a history of dyspnea from 10 years ago, developed increased sputum production, coughing and blood- streaked sputum and hospitalized for further investigations. He was a current smoker (17pack/year) and oral opium addict. Spirometry revealed severe airflow obstruction with FVC: 45%, FEV1: 31%, and FEV1/FVC: 51%. Considering cheat x-ray findings, the patient underwent chest HRCT (Figures 1 A and B). Serum immunoglobulins and IgG subclasses assessment and sweat test were performed and all were normal. Biochemistry tests were also performed, and liver and renal function tests, electrolytes, peripheral blood leukocyte counts, hemoglobin, and platelet count were all normal. ESR was 57mm/hr, and serum as well as sputum galactomannan were negative for aspergillosis. Bronchoscopy was performed; bronchoalveolar lavage fluid smear and culture were negative for pathogenic bacteria, fungi, and mycobacterium. Histopathological examination of the bronchial biopsy specimen showed chronic non- specific inflammation.