A 36-year-old female patient was admitted to our hospital due to chronic cough, expectoration, chest tightness and wheezing. She is a never smoker. She had experienced chronic sinusitis since the age of 12 and started experiencing cough and purulent sputum at the age of 20. The symptoms progressively worsened, presenting with exertional dyspnea and constant wheezing. At the age of 25, the patient underwent “thoracotomy drainage and biopsy” in the local hospital due to “empyema and pleural effusion.” Physical examination on admission revealed diffuse expiratory wheezes and coarse crackles in both lungs. Pulmonary function test showed that the ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV1/FVC) was 43.39% (). Blood gas analysis showed hypoxemia with an oxygen partial pressure (PaO2) of 62 mmHg and oxygenation index of 155 mmHg. Chest high-resolution computed tomography (HRCT) scan showed well-defined multiple centrilobular nodules and diffuse tree-in-bud pattern (). No obvious abnormalities were found in routine blood tests, procalcitonin, sputum smear microscopy, sputum culture, tuberculosis bacili gamma interferon release test, rheumatoid factors, humoral immunity, connective tissue related antibodies, anti-neutrophil cytoplasmic antibody, etc. On the first admission, the patient’s symptoms improved after symptomatic treatment such as antitussive, expectorant and antiasthmatic treatment and discharged from the hospital automatically.\nHowever, the patient presented with the above symptoms repeatedly and was hospitalized in our hospital again after 1 month. On this admission, we performed further investigations on this patient. Paranasal sinus CT showed bilateral maxillary sinus inflammation (). Cold agglutinin level was in the normal range. A diagnosis of diffuse panbronchiolitis was made given the symptoms, signs, history of sinusitis, radiological, pulmonary function and laboratory findings. In this hospitalization, we treated the patient with azithromycin (500 mg per day), and the respiratory symptoms of the patient were obviously improved. However, dyspnea symptoms of the case 1 were not well controlled, so we treated the patient with prednisone acetate for 12 months. The dose was gradually reduced from 30 mg to 10 mg per day and finally stopped.\nSince then, the patient has been followed up at our hospital for 2 years, sometimes hospitalized for deterioration of her condition. Sixteen months after the definite diagnosis, the patient was hospitalized again in our hospital for cough, expectoration and dyspnea. Chest CT showed a small nodule at the upper tip of the right lung (). Sputum culture showed a small amount of Pseudomonas aeruginosa growth (++). Fiberoptic bronchoscopy revealed abundant purulent secretions in the left and right main bronchi and all levels of bronchi (). Bronchoalveolar lavage fluid culture showed that Pseudomonas aeruginosa was 300 colony-forming units per milliliter (CFU/ml). The second bronchoscope lavage fluid smear revealed 1 root of acid-fast bacilli/300 visual field, and the culture showed a small amount of fusarium. Mycobacterium tuberculosis complex group DNA was positive. The patient was diagnosed as secondary pulmonary tuberculosis and received anti-tuberculosis treatment with isoniazid, rifapentine, ethambutol and moxifloxacin. Since then, the patient has received anti-tuberculosis treatment for up to 12 months. The patient’s condition gradually improved and the nodule in the right lung showed significant shrinkage () after anti-tuberculosis treatment.
A 60-yr-old woman referred for a 5-yr history of severe asthma on 18th August 2010. Cough and dyspnea were her main symptoms. Her initial FEV1 was 0.88 L (42.9%), FVC was 1.10 L (44.9%), and FEV1/FVC was 73.4% without a BD response. A crackling sound was heard in both lungs. A chest CT showed diffuse bronchial wall thickening and centrilobular nodules with a tree-in-bud appearance in both lower lungs (). Induced sputum showed 2% eosinophils. A MBPT could not be performed. Water's view showed bilateral maxillary sinusitis. She had been using inhaled budesonide combined with formoterol, a tiotropium inhaler, montelukast, and theophylline for a month. After a month, she complained of continuous cough and sputum. The crackling sound was consistently heard. The AFB studies were negative, and clarithromycin was introduced. The patient took clarithromycin 250 mg twice a day for 5.5 months with asthma medication, after which her FEV1 improved from 0.88 L (42.9%) to 1.96 L (97.1%), and FVC improved from 44.9% to 98.8%. Follow-up chest CT after a year showed improved centrilobular nodules in both lungs. She was able to discontinue budesonide and formoterol.