A 73-year-old white woman presented in 1993 with a barking cough, left-sided chest pain, shortness of breath, and night sweats. She was an ex-smoker, having given up smoking at 44 years of age. She had been slightly short of breath on exertion for many years with spirometry showing an FEV1 of 1.1 L and FVC of 2.0 L, with a normal carbon monoxide transfer factor. She had no history of exposure to TB. She had previously worked in a tile-making factory, where she was exposed to tile dust, and for 5 years as a printer, although inhalational exposure at workplace was reported to be minimal. Her chest radiograph in 1965 had revealed increased density in the right hilum. At presentation in 1993, the chest radiograph revealed a suspected mass in the right hilum. Her CT scan showed bilateral calcified nodes, dense linear scars in the right middle lobe (RML), which were presumed to be fibrotic, and some possible interstitial fibrosis in both upper lobes. The possibility of TB as a cause for the abnormal calcified lobes was raised, although the etiology may have also have been due to occupational exposure to silica. Bronchoscopy was performed, and large, black, slightly raised patches were found on both the main bronchi and all lobar bronchi. The left lower lobe (LLL) orifice and both upper lobe orifices were narrowed but not tightly stenosed. A differential diagnosis of melanoma or Kaposi sarcoma was suggested. The mucosa bled heavily when bronchial brushings were attempted, and cytology of the specimens showed no malignant cells but numerous macrophages containing fine black pigment. The patient was referred for rigid bronchoscopy. These samples confirmed probable carbon-laden macrophages and the results of staining with S-100, Masson Fontana, and HMB-45 were all negative for melanoma. She remained clinically and radiologically stable until 2005 but has had an increasing frequency of hospital admissions with infective exacerbations of COPD since then. In September 2006, the patient presented with a large left-sided pleural effusion, and repeat bronchoscopy showed similar findings to those of the 1993 bronchoscopy except that the 2006 bronchoscopy showed that the left upper lobe (LUL) orifice was totally stenosed by pigmented material (Fig 1, top left, A).