Differential Diagnosis for a Middle-Aged Lady with Chronic Productive Cough and Weight Loss

Single Most Likely Diagnosis

• Tuberculosis (TB): The chronic productive cough with green-yellowish sputum, significant weight loss, and the "tree-in-bud" appearance on imaging, which is indicative of bronchiolar plugging, along with mediastinal lymphadenopathy, are highly suggestive of pulmonary TB. The presence of bilateral ronchi, wheezes, squeaks, and crackles also supports this diagnosis.

Other Likely Diagnoses

• Bronchiectasis: This condition could explain the chronic productive cough and the presence of bilateral ronchi and crackles. However, the significant weight loss and "tree-in-bud" appearance are less typical for bronchiectasis alone.
• Sarcoidosis: This disease can cause mediastinal lymphadenopathy and pulmonary symptoms, including cough and weight loss. The "tree-in-bud" pattern can be seen in sarcoidosis, especially in the context of bronchial involvement.
• Lymphoma: Although less common, lymphoma could explain the mediastinal lymphadenopathy, weight loss, and pulmonary symptoms. The "tree-in-bud" pattern could be seen in lymphomatous involvement of the lungs.

Do Not Miss Diagnoses

• Lung Cancer: Given the significant weight loss and chronic cough, lung cancer must be considered, even though the "tree-in-bud" pattern is not typical. Metastatic disease to the lungs could also present with similar symptoms and imaging findings.
• Invasive Aspergillosis: In immunocompromised patients, invasive aspergillosis can present with similar pulmonary symptoms and imaging findings, including the "tree-in-bud" appearance. Although the patient is described as "medically free," any degree of immunosuppression could increase the risk.

Rare Diagnoses

• Cystic Fibrosis (Late-Onset): Although rare in adults, late-onset cystic fibrosis could present with chronic productive cough, weight loss, and bronchiectasis, which might show a "tree-in-bud" pattern on imaging.
• Histiocytosis X (Langerhans Cell Histiocytosis): This rare condition can cause pulmonary symptoms, including cough and weight loss, along with distinctive radiographic findings that might include a "tree-in-bud" pattern in some cases.
• Immunoglobulin G4-Related Disease (IgG4-RD): This condition can involve the lungs and cause symptoms similar to those described, along with mediastinal lymphadenopathy. However, it is relatively rare and would require specific diagnostic testing for confirmation.