What is the likely diagnosis for a patient with a 2-year history of productive cough, no smoking history, and previous long-term occupational exposure in a factory, presenting with rhonchi on auscultation and vital stability?

Occupational Chronic Bronchitis (Byssinosis)

The most likely diagnosis is occupational chronic bronchitis (byssinosis), given the 2-year history of productive cough meeting clinical criteria (most days for 2 years), long-term factory exposure to organic or inorganic dusts, non-smoking status, and presence of rhonchi indicating chronic airway inflammation with mucus hypersecretion. 1

Why Occupational Chronic Bronchitis is the Primary Diagnosis

• The temporal relationship is diagnostic: The productive cough began precisely 2 years ago when the patient retired from factory work, indicating symptom onset coincided with cessation of exposure, though chronic airway inflammation persists from years of cumulative dust exposure. 1

• Clinical criteria are met: Productive cough "most of the days" for 2 years satisfies the definition of chronic bronchitis (productive cough for at least 3 months per year for 2 consecutive years). 1

• Rhonchi on auscultation indicates chronic airway inflammation and mucus hypersecretion, which are hallmark features of occupational chronic bronchitis rather than the wheezing typically heard in asthma. 1

• Non-smoking status makes this diagnosis more specific: Approximately 15% of chronic bronchitis and COPD cases are attributable to occupational exposures, particularly organic dust, cotton, hemp, linen, jute, sisal, and other industrial dusts in workers with prolonged factory exposure. 1, 2 The absence of smoking history strengthens the occupational etiology. 1

Why the Other Options Are Less Likely

Option A: Asthma - Unlikely

• Asthma lacks the key clinical features present in this case: The patient has no wheezing, dyspnea, or episodic symptoms that characterize asthma. 1

• Rhonchi rather than wheezes suggest chronic bronchitis with fixed mucus production rather than reversible airway obstruction seen in asthma. 1

• The pattern is wrong: Asthma typically presents with variable symptoms that improve and worsen, not a constant productive cough for 2 years. 3

Option B: COPD - Possible but Less Precise

• COPD requires spirometry confirmation: The diagnosis of COPD cannot be made without objective measurement showing fixed airflow obstruction (post-bronchodilator FEV1/FVC <0.7). 3, 4, 5 No pulmonary function testing has been performed yet.

• COPD is a broader category: While occupational chronic bronchitis can progress to COPD, this patient may have chronic bronchitis without fixed airflow obstruction. 1 Spirometry must be performed to assess for fixed airflow obstruction using FEV1 and FEV1/FVC ratio. 1

• Occupational chronic bronchitis is the more specific diagnosis at this stage, with COPD being a potential progression if spirometry confirms irreversible obstruction. 2, 6

Option C: Chronic Eosinophilic Pneumonia - Very Unlikely

• Systemic features are absent: Chronic eosinophilic pneumonia typically presents with fever, weight loss, night sweats, and peripheral eosinophilia—none of which are mentioned. 1

• Imaging findings are missing: This diagnosis requires infiltrates on chest X-ray, which were not reported. 1

Option D: Chronic Aspergillosis - Very Unlikely

• No supporting clinical features: Chronic aspergillosis typically occurs in patients with pre-existing lung cavities, immunosuppression, or chronic lung disease with specific radiographic findings. 1

• The clinical presentation doesn't fit: The productive cough and rhonchi are more consistent with diffuse airway disease rather than focal fungal infection.

Essential Next Steps

Spirometry with bronchodilator testing must be performed to objectively confirm or exclude fixed airflow obstruction consistent with COPD, and to assess severity using FEV1 and FEV1/FVC ratio. 1

Management Algorithm

1. Confirm the diagnosis with detailed occupational history documenting specific exposures (cotton, hemp, linen, jute, sisal, metal dusts, silica, coal dust, or other industrial irritants). 3, 1

2. Perform spirometry to determine if fixed airflow obstruction is present:

   • If FEV1/FVC <0.7 post-bronchodilator → diagnose as occupational COPD 1, 4
   • If spirometry is normal or shows only mild obstruction → occupational chronic bronchitis without COPD 1

3. Initiate bronchodilator therapy if spirometry confirms airflow obstruction, starting with short-acting beta-2 agonists or anticholinergics as needed. 1

4. Emphasize avoidance of further occupational exposures or environmental irritants, though the patient has already retired. 1

5. Consider corticosteroid trial if moderate to severe airflow obstruction is documented on spirometry. 1

Critical Pitfalls to Avoid

• Do not dismiss this as simple "smoker's cough" when the patient doesn't smoke—occupational chronic bronchitis is commonly missed by clinicians despite accounting for 15% of chronic bronchitis cases. 1, 2

• Do not diagnose COPD without spirometry: A firm diagnosis requires objective measurement of airflow obstruction, not just clinical symptoms. 3, 4

• Do not attribute symptoms solely to aging or retirement: The temporal relationship between factory work and symptom onset is diagnostically significant. 3, 1

• Do not forget to document the occupational history in detail: This is essential for potential workers' compensation claims, as occupational chronic bronchitis is recognized in European occupational disease lists (code 304.02). 1