Presentation
Exertional dyspnea and chronic dry cough in an active smoker with a 20 pack year history. No occupational exposures.
Patient Data
Biapical patchy ground glass opacities with subpleural and basal sparing. No evidence of traction bronchiectasis, interlobular septal thickening or honeycombing. Mild paraseptal emphysema in both apices. Bilateral gynecomastia is also noted.
Changes may be consistent with hypersensitivity pneumonitis with the patient's smoking history raising the possibility of RB-ILD as a differential.
HRCT 6 months later
Interval near-complete resolution of previously identified biapical ground glass opacities. Mild apical paraseptal emphysema is again demonstrated.
Case Discussion
Respiratory bronchiolitis - interstitial lung disease (RB-ILD) refers to symptomatic smoking related interstitial lung disease which typically presents with progressive dyspnea and chronic cough. It is typically seen in young or middle-aged individuals with a history of heavy smoking. Diagnosis is histological: interstitial inflammation is maximal in respiratory bronchioles and adjacent alveoli and features pigmented macrophages. However biopsy is rarely performed as patients typically remain stable or improve following smoking cessation.
RB-ILD was considered as a differential for this patient at initial presentation given their smoking status, CT appearances and lack of antigen exposure or suggestion of hypersensitivity pneumonitis in the history. The patient was subsequently advised to cease smoking with continued support and counseling through primary health care. At 6 months follow-up, the patient reported improvement in their symptoms which was supported by improved pulmonary function testing and near-complete resolution of previously identified ground glass opacities on repeat HRCT. Further testing through bronchial washings and biopsy were hence not indicated and the patient was discharged from the clinic.
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