Chronic Cough and Bilateral Pneumothoraces in a Nonsmoker Sarah L. O’Beirne, MD, PhD, Joanna G. Escalon, MD, Jordan E. Arkin, MD, Brendon M. Stiles, MD, Robert J. Kaner, MD, Alan C. Legasto, MD, Navneet Narula, MD, Thomas C. King, MD  CHEST  Volume 149, Issue 2, Pages e49-e55 (February 2016) DOI: 10.1016/j.chest.2015.10.070 Copyright © 2016 American College of Chest Physicians Terms and Conditions

Figure 1 Initial chest radiograph (A) demonstrates a small left apical pneumothorax and bilateral subpleural reticulation, most pronounced in the upper lobes. Initial noncontrast high-resolution computed tomography of the chest in the coronal plane (B), axial supine inspiratory view of the apices (C), and axial prone inspiratory view of the bases (D) demonstrates a small left hydropneumothorax and bilateral upper zone predominant irregular pleuroparenchymal thickening, architectural distortion, traction bronchiectasis, and tracheomegaly. There is relative sparing of the lower lobes, which demonstrate nonspecific subpleural reticulations, which can be seen in the setting of usual interstitial pneumonia or idiopathic pulmonary fibrosis. No evidence of honeycombing, bullous disease, or mosaic attenuation is identified. CHEST 2016 149, e49-e55DOI: (10.1016/j.chest.2015.10.070) Copyright © 2016 American College of Chest Physicians Terms and Conditions

Figure 2 Noncontrast high-resolution computed tomography of the chest in the coronal plane (A), axial supine inspiratory view of the apices (B), inferior upper lobes (C), and bases (D) at 5-month follow-up demonstrates new pneumomediastinum extending into the soft tissues of the neck and inferiorly to the level of the diaphragm as well as a new right apical pneumothorax and persistent left apical pneumothorax. There has been interval mild progression of the upper lobe predominant subpleural reticulation. Interlobular septal thickening is present, and the lung bases are unchanged from prior examination. E, Sagittal reformatted views demonstrate anteroposterior flattening of the chest wall. CHEST 2016 149, e49-e55DOI: (10.1016/j.chest.2015.10.070) Copyright © 2016 American College of Chest Physicians Terms and Conditions

Figure 3 Surgical lung biopsy with low-power (×2) magnification with hematoxylin and eosin stain depicting pleural (large arrows pointing to pleura) and subpleural fibrosis and elastosis (A). There is subpleural accentuation of fibroelastosis with an abrupt transition to normal lung tissue (small arrows), and higher-power (×10) magnification with elastic staining demonstrating fragmented elastic fibers and prominent subpleural alveolar septal elastosis obliterating the lung architecture (B). Vascular involvement was also present, with a small muscular artery with recanalized thrombus (short arrow) and medial hyperplasia (long arrow) seen (×10) (C), and another vessel with luminal obliteration and fragmented elastic fibers (×10) (D). CHEST 2016 149, e49-e55DOI: (10.1016/j.chest.2015.10.070) Copyright © 2016 American College of Chest Physicians Terms and Conditions