Alveolar and interstitial disease in chronic smoker presenting as combined pulmonary fibrosis with emphysema: Double trouble!

Abstract

Abstract Tobacco smoke exposure causes diverse pulmonary manifestations with involvement of alveolar, interstitial, and vascular diseases due to inflammatory pathology apart from more lethal lung cancer. Combined pulmonary fibrosis and emphysema is a heterogenous lung disease documented in smokers, which includes emphysema in the upper lobes and pulmonary fibrosis in the lower lobes. In this case report, we have reported an 80-year-old male presented with progressive shortness of breath with fatigability and hypoxia treated as emphysema with inhaled bronchodilators. Response to medical treatment was not satisfactory with worsening of shortness of breath and fatigability. Clinical examination revealed that bilateral basal Velcro crepitation with resting oxygen saturation was 88% at room air. High-resolution computerized imaging documented emphysema in the upper lobes with honeycombing and the lower lobes with tractional bronchiectasis. Echocardiography documented pulmonary hypertension with dilated right atrium and ventricle. We have treated with oxygen supplementation during rest and ambulation, long-acting inhaled bronchodilator medicines, and antifibrotic nintedanib with strict counseling for the avoidance of tobacco exposure. Cardiopulmonary parameters’ improvement including in 6-min walk distance was significant with bronchodilators and antifibrotics.