RESULTS: The patient is a 75 year old male who presented for a 5 month cough recently associated with hemoptysis along with an abnormal CT Thorax at an outside facility. Two courses of Zithromax prescribed by his primary care physician did not alleviate symptoms. No history of post nasal drip, shortness of breath, fevers, or weight loss was reported. Physical examination was unremarkable. An outpatient CT Thorax done recently showed tree-in-bud appearance within left lower lobe with calcific lesions seen within the proximal left mainstem bronchus (LMSB). PFT’s done showed FEV1/FVC of 75%, FEV1 of 80 with no significant change with bronchodilators, TLC of 84, RV of 98, and DLCO of 84. Bronchoscopy showed yellow, mass like densities in the LMSB with inflamed and thickened mucosa noted at the base. The base of the mass also looked necrotic with irregular borders. Bronchial washing and tissue biopsies were obtained from the LMSB. The patient returned to the office after the bronchoscopy with his cough unchanged. All cultures and biopsies from the bronchoscopy came back negative. Given his persistent cough and bronchoscopic findings with negative cultures and biopsies, an esophagram was done which was suggestive of a TEF. A subsequent EGD was unable to locate the fistula but a specialized US guided EGD was successful in locating a TEF. The patient He denied any history of trauma, previous intubations, or specific relation of his symptoms to food intake. He had an expandable stent placed with significant resolution of his symptoms over the following week.