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, spirometry with reversibility testing 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) 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 functional status as compared to those with anthracosis only. On imaging, multifocal bronchial narrowing was specific to BAF.

Pulmonary tuberculosis masquerading as metastatic lung diseaseA 30-year-old, HIV-negative female, who had never smoked, was referred for evaluation of lung metastasis. She had abdominal pain, occasional fever and weight loss for 3 months. Progressive breathlessness was present for 15 days. Her physical examination was unremarkable. Chest radiography (figure 1) showed bilateral nodular opacities with indistinct margins in all the lung zones. Computed tomography (CT) of the thorax demonstrated multiple round nodules of variable sizes scattered throughout both lung fields, suggestive of metastatic lung disease. Abdominal ultrasonography revealed multiple large retroperitoneal lymph nodes, which were confirmed on CT. Several sputum samples for acid-fast bacilli (AFB) and malignant cytology were negative. Her bronchial aspirate was positive for AFB and GeneXpert (Cepheid, Sunnyvale, CA, USA) detected Mycobacterium tuberculosis without rifampicin resistance. Transbronchial biopsy revealed caseating granulomas consistent with pulmonary tuberculosis. She was then referred to DOTS (directly observed therapy, short course) centre for initiation of antituberculous therapy. Subsequently, the bronchial aspirate also cultured M. tuberculosis.The typical presentation of pulmonary tuberculosis is easily recognisable but the disease, a well-known masquerader, can be a source of diagnostic confusion radiologically when the presentation is atypical. The most common and feared cause of multiple round opacities of varying sizes in the lungs is metastasis. Pulmonary tuberculosis, as a cause of such a radiological presentation, is very rare, with only sporadic reports [1-3] documenting such an appearance. In an appropriate setting, pulmonary tuberculosis should be considered in the differential diagnosis of bilateral pulmonary nodules simulating metastasis. This could possibly prevent invasive interventions being performed to establish a diagnosis [2].

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.

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.

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.