Pulmonary Tuberculosis is caused by bacilli mycobacterium tuberculosis and known to infect human race since the dawn of history and archaeological evidence has traced its association in neolithic times. Tuberculosis is the most common infectious lung diseases in India with significant mortality and morbidity. Tuberculosis can cause diverse thoracic presentations ranging from nodules, consolidations & cavitation, mediastinal adenopathy, pleural effusion to diffuse endobronchial disease presenting like bronchial asthma. Due to diverse presentations, diagnosis is many times delayed due to lack of suspicion by treating general physicians and rational treatment many not offered in time. In spite of awareness by government organizations and considered as ‘global health issue of concern’ by World Health organization, tuberculosis is still considered as social stigma. Destroyed lung is described in literature and known complication of pulmonary tuberculosis. Destroyed lung is defined as combination of pleural and parenchymal lung destruction with cavitation, bronchiectasis, loss of lung volume and mediastinal herniation to diseased side. In this case series, we have reported two cases with history of pulmonary tuberculosis in past and received adequate anti-tuberculosis treatment. Both were having residual chronic lung disease and symptoms causing significant impact on quality of life with recurrent hospitalization, hospital visits and cost of care. One patient has history of delayed diagnosis and ATT was started after maximum lung destruction due to tuberculous process has already occurred. In this patient tuberculosis was cured but residual lung damage or sequel presenting as destroyed lung. In second case, tuberculosis was diagnosed in adequate time but patient has defaulted due to adverse events of ATT and he has taken medications as per his own tolerance. Neither adherence nor compliance was acceptable in second case and resulted into partially treated case of pulmonary tuberculosis. Ongoing lung destruction inn second case would be cause for destroyed lung in absence of irrational medicines in today’s era of good quality ATT. Destroyed lung is preventable with early diagnosis, prompt evaluation with microscopy and nucleic acid amplification tests and treatment with universally available, acceptable and affordable free ATT as National guidelines. Destroyed lung is having significant impact on quality of life and health expenditure and considered as ‘radiological stigma’ of Tuberculosis.

Long COVID is more prevalent chronic health care issue in post COVID care settings. We are in great piece of relief due to nearly end of this deadly pandemic which has caused significant change in routine of entire globe. Long COVID is an unpredicted sequel of COVID-19 disease documented nearly in half cases globally. Long COVID is multisystem syndrome with nonspecific symptoms and organic signs of unidentified pathology occurs after COVID-19 disease. Long COVID symptoms has been documented in ‘selected’ cases irrespective of disease severity or hospitalization and possible link remains unknown. Long COVID symptoms has significant impact on quality of life in those cases suffered from disease in recent past and lingering to almost two years since infection. Importantly, not all cases of COVID-19 were shown long COVID symptoms. Most common long COVID symptoms as joint pain, fatigability, chest discomfort, shortness of breath, hair loss, chest pain, weight gain, anxiety/depression & memory impairment. Pathophysiology resulting into long COVID manifestations is still not completely validated. Researchers have reported ‘immune dysregulation’, ‘autoimmunity’, ‘antigenic mimicry’ & ‘coagulation abnormalities’ are probable pathophysiological mechanism for long COVID. Some of the long COVID effects shown complete reversibility including post COVID lung fibrosis. Reboot system to restore immune dysregulation and recovery in long COVID is real concern. Long COVID symptoms cases are more health conscious and usually follows pattern of doctor shopping due to underestimation by family physicians either due to lack of suspicion or lack of knowledge regarding treatment protocol. Still, we are not having right answer for exact duration of long COVID symptoms and when it will show complete reversibility. Further, it needs ‘birds eye vision’ to pick up and manage cases with long COVID manifestations during routine care in rehabilitation unit.

Long COVID is an unpredicted sequel of COVID-19 disease documented nearly in half cases globally. Long COVID is multisystem syndrome with nonspecific symptoms and organic signs of unidentified pathology occurs after COVID-19 disease. Long COVID symptoms has been documented in some cases irrespective of disease severity or hospitalization. Long COVID symptoms has significant impact on quality of life in those cases suffered from disease in recent past and lingering to almost two years since infection. Importantly, not all cases of COVID-19 were shown long COVID symptoms. Most common long COVID symptoms (ten in number) as joint pain, fatigability, chest discomfort, shortness of breath, hair loss, chest pain, weight gain, anxiety/depression & memory impairment. Pathophysiology resulting into long COVID manifestations is still not completely validated. Researchers have reported ‘immune dysregulation’ and ‘coagulation abnormalities’ are probable pathophysiological mechanism for long COVID. Some of the long COVID effects shown complete reversibility including post COVID lung fibrosis. Reboot system to restore immune dysregulation and recovery in long COVID is real concern. Long COVID symptoms cases are more health conscious and usually follows pattern of doctor shopping due to underestimation by family physicians either due to lack of suspicion or lack of knowledge regarding treatment protocol.

Community acquired pneumonia is the most common cause for lung parenchymal infiltrates in chest radiograph in scenarios with acute febrile respiratory illness. Tuberculosis in India accounts for the highest number of cases and deaths in the world. In spite of an efficient National tuberculosis control program for five decades, Tuberculosis is still the number one cause of death due to infectious agents in India and one third of total global deaths occurs in India due to this disease. Tuberculosis may present with consolidation, cavitation, coin lesion, parenchymal infiltrates and hilar mass like lesions. Acute febrile respiratory illness without typical constitutional symptoms is not frequently described in pulmonary tuberculosis. In this case report, a 69-year male, presented with acute febrile respiratory illness of short duration. He was having high grade fever, cough, shortness of breath & haemoptysis of less than two weeks duration. His symptoms were progressive and empirically treated as lower respiratory tract infection or community acquired pneumonia with oral and intravenous antibiotics by general physicians and family physicians. Family physician referred to our center for worsened general health with increased shortness of breath with episodes of minimal haemoptysis. Chest x-ray documented right lower lobe consolidation which has progressed to central cavitations and thick pericavitary rim of consolidation mimicking lung abscess. Clinically he was having crepitations in the right inframammary and infrascapular area with egophony heard. HRCT thorax showed consolidation with cavitation in the superior segment of the right lower lobe and adjacent small cavity in the posterior segment presenting as a ‘Sister cavity’ accompanying a large parent cavity. He was unable to produce sputum and we have processed induced sputum examination which has documented acid-fast bacilli in smear and MTB genome with rifampicin sensitivity in cartridge based nucleic acid amplification test. Initially, microbiologists refused for smear preparation due to salivary nature and poor-quality sputum. We have insisted for microbiology workup due to high chances of yield due to cavitary lung disease and noted positive yield. Treatment initiated with anti-tuberculosis (ATT). We have recorded near complete radiological resolution, bacteriological cure after eight months of ATT with good compliance. Acute febrile respiratory illness and absence of typical constitutional symptoms is not uncommon. Although cavitating consolidation is commonly described in community acquired pneumonia, presence of ‘sister cavity’ is a radiological clue to think and proceed to workup towards active pulmonary tuberculosis. Induced sputum has a very significant impact on diagnostic yield. Pulmonary tuberculosis should be suspected early in cases with cavitating consolidations to have a successful treatment outcome.

Lung cancer is usually diagnosed at a late stage due to a lack of awareness of symptoms to the patient, absence of screening trends by performing chest imaging, and lack of sensitization to the most common radiological signs of lung malignancy to family physicians. Radiological signs will help in suspecting lung cancer earliest and important role in guiding for a protocolized workup to rule out underlying malignancy. “Sunray sign” in chest radiograph is the first time described in the literature and constitutes hilar mass or radiopacity with inhomogeneous linear opacities spreading toward peripheries like sunrays which is the marker of interstitial lymphatic involvement due to the malignant spread of disease. “Sunray sign” is an indicator of underlying lung malignancy with central airway or mainstem bronchus involvement with lymphatic dissemination in linear opacities. In this case report, we have reported a 51-year male presented with cough and hemoptysis with progressive worsening of shortness of breath. Chest X-ray documented round opacity occupying left hilum with linear opacities emerging toward peripheries in lung parenchyma showing typical “Sunray sign.” Bronchoscopy was done after clinical stabilization and showed endobronchial polypoidal growth in the left mainstem bronchus causing partial occlusion of the bronchial lumen. Endobronchial needle aspiration cytology and forceps-guided histopathology suggestive of “squamous cell” type of lung malignancy for “Sunray sign” in our case. A high index of suspicion is a must to rule out underlying malignancy and Bronchoscopy is a “gold standard” test in cases with Sunray signs to confirm the diagnosis.