A 42-year-old Caucasian woman presented with dyspnoea and expectoration of white stringy phlegm with a consistency between goat’s cheese and chewing gum (fig 1). She had had recurrent respiratory infections since childhood. In 1997 she noticed exertional dyspnoea and in 1999 she started producing bronchial casts. Pulmonary fibrosis was diagnosed based on a high-resolution CT scan which showed ground-glass opacities consistent with active early fibrosis. Prednisolone was started following an open lung biopsy which revealed bronchiolitis with peribronchial inflammation-associated fibrosis. Subsequent scans showed reduced alveolitis but progressive fibrosis. In 2004, tuberculosis was diagnosed on sputum culture and treated. Cultures have remained negative since. Azathioprine was introduced …