A man in his 60s presented with progressive bulbar dysfunction, exertional dyspnoea and nocturnal respiratory disturbance. His symptoms began a decade earlier with throat clearing, mild dysphagia and sleep disruption, initially attributed to obstructive sleep apnoea treated with continuous positive airway pressure. Despite therapy, he developed worsening dysphagia, dream enactment, stridor and acute type II respiratory failure requiring emergency intubation and subsequent tracheostomy after repeated failed extubation attempts. Investigations revealed status dissociatus and agrypnia excitata on polysomnography, while serum studies confirmed high-titre anti-IgLON5 antibodies. Immunotherapy with corticosteroids, plasma exchange and rituximab achieved partial improvement, but tracheostomy dependence and bulbar symptoms persisted. He stabilised on nocturnal invasive ventilation and was discharged with coordinated multidisciplinary care. This case highlights the diagnostic pitfalls of attributing progressive neurological features to common mimics, the dual pathology of anti-IgLON5 disease that limits therapeutic response, and the importance of early airway intervention to prevent avoidable mortality.

Although infection accounts for the majority of acute diffuse airspace disease in dyspneic patients with hematologic malignancy, radiologists must also recognize a spectrum of noninfectious pulmonary conditions that can mimic infection. These less common entities are often unfamiliar and diagnostically challenging for radiologists but are also complex diagnoses for clinicians to establish without expert radiologic assistance. The misdiagnosis of infection and associated delays in correct diagnosis in these patients can significantly increase morbidity and mortality. The authors highlight noninfectious causes of dyspnea and associated diffuse parenchymal disease that often manifest with clinical characteristics mimicking infection. These include drug toxicities and treatment-related complications (particularly to new therapies and treatment regimens), associated edema and hemorrhage, complications of primary disease, and associated secondary disorders. Although imaging findings often overlap with those of infection, radiologists aware of these conditions can aid in accurate diagnosis by integrating knowledge of predisposing clinical scenarios, recognizing distinguishing imaging features and their temporal evolution, and correlating with clinical parameters. Although confirmation of these alternate noninfectious conditions is not always possible by imaging alone, radiologic interpretation may prompt additional specific tests that can corroborate the correct diagnosis. Timely accurate diagnoses of noninfectious causes can improve diagnostic accuracy and patient outcomes in this vulnerable population.

Tracheobronchial foreign body aspiration (FBA) is potentially life-threatening. In adults, delayed diagnosis may occur because symptoms are nonspecific and organic foreign bodies can be radiolucent, leading to recurrent infection, granulation tissue, and surgical resection. A 46-year-old Arab man with hypertrophic cardiomyopathy and hypertension presented with fever, productive cough, and grade II dyspnea 15 months after accidental pea aspiration. Chest computed tomography (CT) demonstrated a focal basal right lower-lobe mass-like consolidation, corresponding to the surgically treated basal segments, without a definite radiopaque intraluminal foreign body. Flexible bronchoscopy achieved only partial removal, and histopathology confirmed plant material with nonspecific chronic inflammation. Despite conservative treatment, he deteriorated with foul-smelling purulent sputum and persistent inflammation. Because of failed conservative/endoscopic management, bronchial strictures, and vegetative inflammatory lesions, he underwent right lower-lobe basal segmentectomy via thoracotomy. Surgery revealed marked induration, consolidation, and a purulent collection. Final pathology showed chronic suppurative inflammation with lymphoid follicles and purulent material, plus a 1.3-cm sclerosing nodule with papillary formations; immunohistochemical evaluation was requested to further exclude an associated neoplastic process. At 2-week follow-up, he improved clinically, and chest radiography showed no residual or recurrent focal mass-like consolidation. Adult FBA may mimic malignancy or chronic infection. CT is essential for identifying secondary postobstructive changes, although the foreign body may not be directly visible. Delayed presentation increases the risk of granulation, infection, and failed bronchoscopic retrieval. Delayed organic FBA should be considered in persistent focal lower-lobe consolidation; early CT and bronchoscopy may prevent complications and surgery.

Chylothorax is an exceptionally rare complication of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), with only a limited number of cases reported in the literature. We present the case of a 66-year-old man who presented with dyspnoea 3 days after EUS-FNA of a paraoesophageal left upper lobe lung mass. Chest radiography and CT demonstrated a left-sided pleural effusion, and image-guided pleural drainage yielded milky fluid whose analysis confirmed chylothorax. He was managed conservatively with a 14-French intercostal chest drain (ICD), dietary modification and octreotide therapy, achieving complete clinical recovery. This case underscores the delayed and potentially under-recognised presentation of post-EUS-FNA chylothorax and raises the possibility that anatomical relationships between thoracic lesions and the thoracic duct may represent a potential risk factor for this uncommon complication.

Diffuse pulmonary meningotheliomatosis (DPM) is an ultrarare diffuse parenchymal lung disease in which pulmonary meningothelial-like nodules produce a miliary radiographic pattern. Most reported cases are asymptomatic and incidentally detected, and longitudinal physiologic data in symptomatic patients remain scarce. A 52-year-old postmenopausal never-smoker presented with three months of progressive exertional dyspnea. High-resolution computed tomography showed innumerable small bilateral nodules in a diffuse, random miliary distribution. A non-dedicated chest CT obtained approximately three months earlier had not described nodules. Serologic and microbiologic workup was unrevealing, and bronchoscopy was nondiagnostic. Video-assisted thoracoscopic wedge resection showed bland spindle-cell nests, and immunohistochemistry established DPM. Serial pulmonary function testing showed moderate restriction with reduced diffusing capacity and alveolar volume. During follow-up, forced vital capacity and six-minute walk distance improved, while static volumes and the diffusing-capacity deficit persisted. Severe obesity likely contributed to the restrictive defect. At reduced alveolar volume, the transfer coefficient (KCO) remained lower than expected for pure extrapulmonary restriction, raising the possibility of an intrinsic pulmonary component. However, obesity, possible pulmonary vascular disease, and other factors precluded attribution of these abnormalities to DPM alone. Management was conservative, without corticosteroids, and the disease burden remained radiographically stable. Symptomatic DPM may show functional improvement despite persistent restriction and impaired diffusing capacity. DPM should be considered among the causes of diffuse miliary opacities when imaging and serologic evaluation are nondiagnostic.

A 27-year-old man presenting with cough, dyspnea, and an abnormal chest radiograph was clinically suspected of having a pulmonary aspergilloma. Histopathological examination of the resected lung tissue demonstrated a dense aggregation of branching, septate hyphae, and partial β-tubulin gene sequencing identified the isolate as Aspergillus flavus. Antifungal susceptibility testing showed the lowest MIC for posaconazole (0.125 μg/mL) and the highest for amphotericin B (4 μg/mL) and 5-fluorocytosine (>64 μg/mL). The patient was discharged after a 16-day hospitalization with complete clinical recovery and was prescribed oral itraconazole for continued outpatient management.