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Combined pulmonary fibrosis and emphysema

A 77-year-old man with a 45 pack-year smoking history presented with exertional dyspnea and dry cough for a year. He had sustained a hip fracture that was treated by open reduction and internal fixation. Shortly after this, the dyspnea worsened and occurred at rest. He was in hypoxemic respiratory failure. Chest auscultation revealed bilateral basal fine end-inspiratory crackles. High-resolution computed tomography of the chest showed large apical bullae, paraseptal and centrilobular emphysematous changes and basilar and peripheral reticular opacities with honeycomb cysts, and traction bronchiolectasis (Figures 1, 2, and 3). Emphysema and lung fibrosis are thought to be divergent responses to smoking, and rarely occur together in the same patient. Figure 1. Chest computed tomography (horizontal section) showing large emphysematous bullae in the upper zones bilaterally.