Dyspnea

Blood gas analysis showed hypoxemia.

Figure 1. Chest X-ray (PA view) reveals interstitial pattern, predominantly ground glass and reticular opacities in bilateral mid and lower thoracic zone and hyperlucency in bilateral upper thoracic zones. No evidence of pleural effusion or cardiomegaly.

Figure 2A. High Resolution computerized tomography (HRCT) sequential axial lung window images scan through upper thoracic zones reveals presence of paraseptal and centrilobular emphysema with subpleural bullae formation.

Figure 2B. High resolution computerized tomography (HRCT) sequential axial lung window images scan through mid and lower thoracic zones shows peripheral honeycombing, ground glass and reticular opacities, and traction bronchiectasis resulting parenchymal architectural alteration.

Figure 2C. High resolution computerized tomography (HRCT) sequential axial lung window images scan through mid and lower thoracic zones shows peripheral honeycombing, ground glass and reticular opacities, and traction bronchiectasis resulting parenchymal architectural alteration.

Diagnosis: Combined pulmonary fibrosis and emphysema (CPFE) 

Cigarette smoking is a recognized risk factor for development of interstitial lung disease (ILD) and combined pulmonary fibrosis and emphysema (CPFE).

There is increasing clinical, radiologic, and pathologic recognition of the coexistence of emphysema and pulmonary fibrosis in the same patient.

Clinical symptoms and signs include exertional dyspnea, cough, wheezing, perioral cyanosis, asthenia, bibasilar inspiratory crackles, and finger clubbing.

Lung function and gas exchange, and imaging studies (X-ray, HRCT Thorax, MRI, and echocardiography for screening and diagnosis of pulmonary hypertension) are key in diagnosis of this condition.