Sir, We read with great interest the editorial published on diffuse pan bronchiolitis (DPB).1 In last three decades, we have seen three cases of DPB diagnosed without any need for a surgical lung biopsy and managed as per the guidelines.2 Two cases have been published previously with rare associations of thymoma and common association of bronchiectasis.3,4 We present the third case of nearly a decade long follow-up of a patient with DPB with the clinical course and radiology. Data on long-term follow-up are scarce. A 49-year-old female residing in nearby locality of our medical college was referred by her general physician for an opinion to the respiratory medicine department for cough and breathlessness. The patient had a history of cough and breathlessness grade 1 for 1 year and took some medications with no relief. She was a nonsmoker, home visit revealed no relevant environmental or bystander exposures. She was an homemaker. She had no history of atopy in self or family. Her general examination revealed some crackles and a normal saturation. She was evaluated with a high-resolution computed tomography (HRCT) of the thorax in 2012 Figure 1a which showed bilateral centrilobular nodules with subtle bronchiectasis and some emphysematous changes. The HRCT of paranasal sinuses suggested pan sinusitis. Her serum immunoglobulin E (IgE) and serum alpha anti-trypsin levels were normal. Serum Ig workup done to rule out immunodeficiency disorders revealed an elevated S. IgG. A follow-up CT done in the next 6 month was static with lung functions also were static in 2012. She was managed on inhaled bronchodilators over the next 2 years. In view waxing and waning symptomatology and the spirometry showing an obstructive abnormality with Forced Expiratory Volume in 1 s (FEV1) of 71% predicted in 2014, a review of diagnosis with multi-disciplinary discussion concluded that the patient had DPB as she satisfied the diagnostic criteria and other differential diagnosis were already ruled out. She was treated with 6 months of azithromycin therapy with relief of symptoms. Subsequently, the patient had infrequent only yearly follow-ups for yearly flu vaccinations as she shifted residence to now 60 km away from the medical college. She was lost to follow up from 2018 to 2021. She was treated with Anti-tuberculosis therapy (ATT) in 2021 at the urban health care center in view of a sputum genexpert report suggesting mycobacterium tuberculosis (MTB) detected, rifampicin resistance not detected with static CXR findings. Posttuberculosis (TB) therapy, she visited our department again due to worsening of dyspnea to grade 2–3, increasing cough and frequent exacerbations. Her baseline saturation now in 2015 was 93%. Her lung functions dropped to an FEV1 of 51% predicted. Her HRCT in 2025 Figure 1b showed progression of the radiology in terms of emphysema, bronchiectasis with fibronodular changes.Figure 1: High-resolution computed tomography thorax image showing (a) Image of year 2012 with nodules, bronchiectasis and emphysema, (b) image of year 2025 with fibronodular changes, bronchiectasis and progressing emphysemaShe now showed clinical and radiological features of a chronic lung disease with progression like chronic obstructive pulmonary disease/bronchiolitis. Whether the DPB progressed or the post-TB sequelae impacted her lung status in the last 4 years is a matter of debate though review of radiology suggested more possibility of progression of DPB. She was managed with pulmonary rehabilitation and bronchodilators with counseling for regular follow-ups. Our case’s clinical course concurs with literature findings2 of DPB behaving like a slow progressing chronic respiratory disease and need for regular follow-up and pulmonary rehabilitation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Desai et al. (Sat,) studied this question.