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Cough’s postulates
  1. Michael Vaclav Holmes,
  2. Eleanor M Giddings,
  3. John Rees
  1. Guys and St Thomas NHS Trust, Respiratory Medicine, Westminster Bridge Road, London SE1 7EH, UK
  1. Michael Vaclav Holmes, mvholmes{at}

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A 26-year-old Caucasian woman with lifelong asthma experienced several months of productive cough and persistent wheeze. Chest radiography was normal. Spirometry revealed an obstructive picture (forced expiratory volume in 1 s (FEV1) 2.34 litres, forced vital capacity (FVC) 3.72 litres; FEV1/FVC 63%) as expected for asthma. Bronchoscopy, performed in view of a positive aspergillus ELISA (enzyme linked immunosorbent assay), showed white plaques visible throughout the trachea (fig 1). Biopsy of the plaques revealed caseating granulomata with acid-fast bacilli visible on smear. Aspergillus was not isolated.

Figure 1

Initial bronchoscopic appearance of trachea demonstrating granulomatous mucosal plaques.

Endobronchial tuberculosis may cause airflow obstruction and rarely, as in this case, presents with a normal chest x ray. In this patient it exacerbated her asthma leading to poor control. Mucosal appearances may mimic bronchial carcinoma.1

Treatment is with standard antituberculous chemotherapy and bronchodilators; macroscopic appearances improve with treatment (fig 2).

Figure 2

Repeat bronchoscopy following 22 weeks of antituberculous therapy demonstrating macroscopic improvement in mucosal lesions.

Patients should undergo repeat bronchoscopy after treatment as subsequent bronchial stenoses are common.2 Segmental tracheal transplantation using bioengineered airways has recently been described3 and offers a promising new treatment for severe airways stenosis.



  • Competing interests: none.

  • Patient consent: Patient/guardian consent was obtained for publication