title: Concomitant upper-lobe bullous emphysema, lower-lobe interstitial fibrosis and pulmonary hypertension in heavy smokers: report of eight cases and review of the literature.
abstract: BACKGROUND
  Smoking can cause a variety of pulmonary interstitial diseases. Pulmonary fibrosis has traditionally been considered a non-smoking-related disease. Recently, however, evidence of smoking-induced fibrosis has emerged.
  
  
  METHODS
  A group of eight patients from the pulmonary clinic in Rabin Medical Center with a combine presentation of fibrosis and emphysema was identified retrospectively. All patients underwent chest computed tomography and pulmonary function tests. One patient underwent lung-heart transplantation and a complete review of his lung pathology was obtained. Transbronchial biopsy was performed in 3 additional patients and echocardiography was performed to evaluate the pulmonary vasculature.
  
  
  RESULTS
  Upper-lobe emphysema with bulluos changes was found in all patients. In addition, a basal interstitial process was recognized, ranging from ground glass opacities to severe pulmonary fibrosis, with honeycombing. The radiological findings matched the pathological results of combined emphysema and usual interstitial pneumonia. Pulmonary function tests were also in accord, showing severe hypoxemia with mild obstruction, normal-to-mildly reduced lung volumes and a severe decrease in diffusion capacity. Most of the patients had moderate-to-severe pulmonary hypertension as well as diffuse coronary artery disease.
  
  
  CONCLUSIONS
  Our findings are in line with emerging evidence that the spectrum of interstitial damage caused by smoke includes not only Langerhans cell hystiocytosis, respiratory bronchiolitis or desquamative interstitial pneumonia but also advanced usual interstitial pneumonitis as well. We believe that in some patients smoking plays a destructive role by a variety of mechanisms and can cause emphysema, lung fibrosis as well as pulmonary vasculopathy and hypertension. Future studies are needed to define the genetics and pathophysiology of this uncommonly reported clinical syndrome.
authors.affiliation: Rabin Medical Center, Radiology Institute, Beilinson Campus, 49100 Petah Tiqva, Israel.
authors.forename: Ahuva
authors.initials: A
authors.lastname: Grubstein
authors.forename: Daniele
authors.initials: D
authors.lastname: Bendayan
authors.forename: Ithak
authors.initials: I
authors.lastname: Schactman
authors.forename: Maya
authors.initials: M
authors.lastname: Cohen
authors.forename: David
authors.initials: D
authors.lastname: Shitrit
authors.forename: Mordechai R
authors.initials: MR
authors.lastname: Kramer
mesh_terms: D000368:Aged; D005260:Female; D016041:Heart-Lung Transplantation; D006801:Humans; D006976:Hypertension, Pulmonary / Q000000981:diagnostic imaging / Q000209:etiology* / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011656:Pulmonary Emphysema / Q000000981:diagnostic imaging / Q000209:etiology* / Q000473:pathology; D011658:Pulmonary Fibrosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000473:pathology; D012129:Respiratory Function Tests; D015656:Respiratory Mechanics; D012189:Retrospective Studies; D012907:Smoking / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed