Figure 1 Quiz of the Week

A 75-year-old female presents with a two-year history of a persistent cough and fatigue. The cough is occasionally productive of purulent sputum. She was treated for a community-acquired pneumonia two years earlier and underwent an anterior cervical discectomy and fusion previously, but is otherwise well. On examination, she appears well-groomed, polite, and thin. Chest auscultation reveals wheezing in the mid zones bilaterally and a later chest X-ray and CT scan demonstrate the findings seen here.

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Image credit: @JRADS.

Answer: Mycobacterium avium-intracellulare

This patient’s clinical presentation and imaging are suggestive of Lady Windermere syndrome, a pulmonary infection with Mycobacterium avium-intracellulare that is limited to the right middle lobe or lingula. The condition, typically seen in elderly immunocompetent females with no significant history of smoking or pulmonary disease, is thought to result from the voluntary suppression of a cough. The accumulation of secretions predisposes patients to infection, especially in the right middle lobe which has a relatively long and narrow bronchus. Imaging demonstrates an interstitial and/or nodular pattern, and sputum or bronchial washings will isolate the responsible organisms. Management is aimed at the underlying infection.

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