1Junior Resident (Post Graduate-III), Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka
2*Professor and HOD, Consultant, Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka. E Mail: bhagyashrisantosh@gmail.com (Corresponding Author)
3Consultant and Associate Professor, Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka
4Consultant and Associate Professor, Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka
5Consultant and Assistant Professor, Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka
6Consultant, Intensivist and Assistant Professor, Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka
7Consultant and Assistant Professor, Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka
8Consultant and Senior Resident, Department of Respiratory Medicine, Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka
Background: Right Middle Lobe Syndrome (RMLS), also called Brock syndrome, includes a recurrent or chronic atelectasis, consolidation, or infection specific to the right middle lobe. This condition results from obstructive factors, such as endobronchial lesions or external compression, or non-obstructive factors like poor collateral ventilation or inflammation. The narrow, horizontally oriented right middle lobe bronchus (RMLB) measures 2-3 cm in length and angles sharply from the intermediate bronchus. Incomplete oblique fissures occur in 20-30% of individuals, which increases the risk of mucus buildup, bacterial stasis, and recurrent pneumonitis. RMLS is often underreported. Its prevalence is 1-2%, with a higher incidence in females (2:1 ratio). The peak age of incidence is between 40 and 60 years, with even higher rates in TB-endemic areas like India, where it can affect up to 15% of endobronchial TB cases.
Case Presentation: A 45-year-old female with uncontrolled type 2 diabetes mellitus and hypertension, presented with a 6-month history of a productive cough that was difficult to expectorate with wheeze. She also reported post-tussive pain, anorexia, and insignificant weight loss, but no fever, or hemoptysis. Past history had CT thorax suggestive of right middle lobe consolidation which improved with appropriate antibiotics. She presented with similar complaints of cough with expectoration, breathlessness on evaluation, a contrast-enhanced CT showed evidence of persistent consolidation in the right middle lobe. Bronchoscopy revealed complete stenosis of the RMLB, and bronchoalveolar lavage CBNAAT trace detected and Pseudomonas putida she was treated with appropriate antibiotics and ATT, during the treatment, patient developed DRESS syndrome which was treated appropriately. After completing 6 months of ATT, she was cured, and repeat bronchoscopy showed a patent RMLB compared to previous bronchoscopy.
Conclusion: This case highlights the diagnostic challenges of RMLS in diabetic patients in TB-burdened settings, the vital role of bronchoscopy with over 90% therapeutic success, and the need for vigilance regarding ATT-DRESS (incidence 1-5%). Early suspicion of tuberculosis in recurrent consolidation with co-morbidities like TB or immunocompromised state should be considered.
How to cite this article: Dhanireddy S, Patil B, Hattiholi J, Gautam S, Pujar K, Antin G, Karalingannavar N, Tangella R. Beyond Recurrent Pneumonia: A Diagnostic Surprise of Middle Lobe Syndrome. Int J Drug Deliv Technol. 2026;16(13s): 549-552. DOI: 10.25258/ijddt.16.13s.61
Source of support: Nil.
Conflict of interest: None