Middle lobe syndrome: An exceptional presentation of concomitant lepidic adenocarcinoma and bronchial anthracofibrosis

Lepidic adenocarcinoma previously known as bronchioloalveolar carcinoma (BAC) is a non-small cell lung cancer with an indolent presentation. Bronchial anthracofibrosis (BAF) is caused by long-standing exposure to biomass fuel smoke often in poorly ventilated kitchen. Middle lobe syndrome (MLS) due to BAF is not uncommon however, lepidic adenocarcinoma then known as BAC, presenting as MLS has been documented only once before in the Polish literature. A 68-year-old never-smoker female with biomass fuel smoke exposure presented with cough and breathlessness. Imaging revealed MLS. Fiberoptic bronchoscopy visualised bluish-black hyperpigmentation with narrowing and distortion of right middle lobe bronchus suggestive of BAF. Transbronchial biopsy confirmed presence of lepidic adenocarcinoma. To our knowledge, this is the first detailed description of lepidic adenocarcinoma and BAF presenting as MLS.