Cough, dyspnoea and purulent sputum in a 66-yr-old nonsmoking female.

A 66-yr-old female presented with dyspnoea on exercise, severe cough, purulent sputum and intermittent chest pain under both costal arches for the last 14 days. Five months prior to admission, pulmonary tuberculosis of both lower lobes had been diagnosed microscopically as the cause of recurrent bilateral pleural and pericardial effusions and pericardial thickening, and the patient was still under a two-drug antituberculous regimen. Loss of weight and fever were denied. She was a nonsmoker. Physical examination revealed wheeze over the left lower chest. The chest radiograph on admission was normal except for pleural thickening at the left lower chest wall associated with a small pleural effusion. Pulmonary function tests showed the following results: total lung capacity (TLC) 4.5 L (70% pred), forced expiratory volume in one second (FEV1) 1.3 L (45% pred), forced vital capacity (FVC) 2.2 L (59% pred), peak expiratory flow (PEF) 51%, maximal expiratory flow when 75% of the FVC remains to be exhaled (MEF75%) 36% pred; FEV1/FVC 83% pred, airway resistance (Raw) 0.55 kPa.L.s and a slight hypoxaemia (9.1 kPa). Because a swab of the throat when cultured grew Escherichia coli, Pseudomonas fluorescens and Staphylococcus epidermidis, oral antibiotics were added to a routine antiobstructive therapy. There was some improvement in the symptoms, but residual cough and dyspnoea persisted. Owing to the development of haemoptysis, fibreoptic bronchoscopy was performed, which showed a tumour almost occluding the entrance of the lingula bronchus (fig. 1). The biopsy of the tumour area is shown in figure 2. Subsequently, the chest radiograph as well as a computed tomographic (CT) scan changed from almost normal to the states shown in figures 3 and 4. After a second bronchoscopy to gain a definitive histology the patient experienced severe paroxysms of coughing.