We did indeed offer the Trust to the Heavens and the Earth and the Mountains; but they refused to undertake it, being afraid thereof: but man undertook it;- He was indeed unjust and foolish

ه� �� ن إ�� ه� ن ا ن� إ�� ن� � ن�ا ن� ن� ن� ن� ن�ا ن� إ� ن� ن� ن� ن� ��ن ن� ن�ا ن� ن� إ� �ن �ن ن� ��ن ن� ن� ن ن�ا ن! إ" ن#ا إ$ ن% ن�� إ& ن' ��ن ن� ن�� إ) ن�� ن�ا ن� %� ن�ى ن* ن+ ن� ن�ا ��ن ن� � ن�ا ن, ن- ن* ��ا ن إ��ل�� ه�و ن0 ل�ا ه�و ن1 ن� ن2ا

The story

A 68 year old Saudi gentleman , a known case of diabetes and chronic atrophic rhinitis presented to us with

•Chronic and recurrent cough

• Shortness of breath

•On and off since 5 years

Chest X-Ray

Lateral view

On examination

vitals stable with SPO2 94

lung examination showed bilateral rhonchi

Investigation CT Chest right middle lobe bronchial

thickening with

distal collapse

hilar mediastinal

lymphadenopathy with suspicion of malignancy

InvestBronchscopy

Brochoscopy

Investigations BAL negative for malignancy

BAL culture –no growth

Bronchial biopsy showed asthma related changes

Investigation Hb 14,

WBC 6.9

Differential showed 16.8% of eosinophils with AEC of 1160

Final diagnosis

Right Middle lobe Syndrome

How do you treat ?

Management

Aggressive asthma treatment

In exacerbations

Lobectomy for bronchiectasis/malignancy

Management Chest physiotherapy and postural drainage

Treat asthma aggressively

Antibiotics in exacerbation

Lobectomy for malignancy/bronchiectasis