“A Case of Bronchiectasis”

" A Case of Bronchiectasis " SIR,-We have read with great interest the report (November 25, p. 1417) of a clinicopathological conference at the Postgraduate Medical School of London on "A Case of Bronchiectasis." Discussion in this case revolved particularly around the problem of gross cystic bronchiectasis in a patient who had suffered from bronchial asthma for many years. Those participating seemed puzzled by the necropsy findings in the lungs, the origin of the cystic spaces, and the time of their development during the patient's prolonged illness. Drs. C. M. Fletcher and J. G. Scadding felt that infection must have played a major part, while Professor J. W. Crofton was prepared to attribute the " bronchiectasis " to tuberculosis. We should like to draw attention to the condition of "mucoid impaction of the bronchi," first described by Shaw." The clinical, radiological, and pathological findings have subsequently been amplified by our own2 and Shaw's3 studies. In brief, patients with bronchial asthma may develop accretions of mucoid material in the more proximal part of their airways (commonly in segmental bronchi). These mucoid plugs may become extraordinarily inspissated, and enlarge by the deposition of further mucoid layers on their surface, producing a laminated appearance on section. They may produce complete bronchial obstruction with distal atelectasis or infection, and they certainly produce gross local dilatation of the bronchus in which they grow. Despite their size (up to three or more centimetres in diameter), situation, and consistency, they may be coughed up, leaving behind large cystic "bronchiectatic " spaces. Clinically the mucoid plugs (and the resultant cystic lesions) may be localized to one segment, one lung, or be widespread. The illness (or in asymptomatic patients the x-ray changes) may be brief or prolonged. The x-ray changes commonly affect different parts of the lungs seriatim over a period which extends from a few months to many years. On careful follow-up, patients are often quite unaware of any clinical features other than those of their asthma to correspond to the episodes of radiological change and structural deterioration. The prognosis varies greatly, for both structure and function. More than one lobe has been surgically resected because a more sinister bronchopulmonary lesion was suspected. We have been unable to find any clinical, bacteriological, or (in resected specimens) pathological evidence of infection in patients who had actively increasing lesions. A certain proportion will develop infection as a result of the bronchial obstruction and distortion produced by the mucoid impactions. The bronchiectasis is not a pre-existing condition-we have seen lesions develop de novo in segments shown by earlier bronchography to be free of bronchiectasis. Apart from these comments we have no evidence to offer on the specific pathogenesis of the condition. Its title is descriptive-no more. Despite this, it would seem reasonable to refer to it by this name, since the condition has been well documented clinically, radiologically, and pathologically. The appearances in the case which was the subject of this clinicopathological conference leave no doubt that it was an example of the syndrome referred to. We are at a loss to understand the reluctance of English clinicians to accept this syndrome of mucoid impaction, which is well recognized in this country.We are, etc.,