Historical Perspective
“Bronchial anthracosis,” a term coined by Pearson [6 ] in 1813, refers to bluish-black discoloration of bronchial mucosa [Figure 1 ]A caused due to soot inhalation. The term BAF was popularized by Chung et al .[5 ] in 1998 when on bronchoscopy they recognized bronchial anthracosis accompanied with
narrowing/distortion of the associated bronchi [Figure 1 ]B. However, it was Abraham Cohen [7 ] who, in 1951, first documented the occurrence of bluish-black pigmentation with
narrowing of airways when he described middle lobe narrowing in eight females due
to perforated tuberculous lymph nodes, six of whom had anthracotic pigmentation. Chung
et al .[5 ] described bronchoscopically confirmed BAF in 28 patients, 20 of whom were females.
Active tuberculosis was seen in 17 of 28 patients while empirical anti-tuberculous
therapy was initiated in 5 of the remaining 11 patients, of whom 3 had definite radiological
improvement. This led the authors to hypothesize that tuberculosis was responsible
for the occurrence of BAF. However, there is now a mounting body of evidence to incriminate
long-standing exposure to the smoke generated by incomplete combustion of biomass
fuel in poorly ventilated kitchens as the causative factor.[8 ],[9 ],[10 ]
Figure 1 (A and B): (A) Fiberoptic bronchoscopic (FOB) image showing bluish-black
anthracotic pigmentation of the mucosa of the left upper lobe bronchus in a 62-year-old
female with 20 years of biomass fuel smoke exposure. (B) FOB image showing bluish-black
anthracotic pigmentation of the mucosa of the right middle lobe bronchus along with
narrowing/distortion of the bronchus suggestive of bronchial anthracofibrosis (BAF)
in a 82-year-old female with 40 years history of biomass fuel smoke exposure
BAF was first reported from India in a 65-year-old female who presented with middle
lobe syndrome (MLS) and had long-standing history of wood-smoke exposure.[11 ] High-resolution computed tomography (HRCT) revealed multifocal narrowing of the
right middle lobe bronchus. Fiberoptic bronchoscopic (FOB) done to evaluate MLS visualized
bluish-black pigmentation along with narrowing and distortion of the middle lobe bronchus
confirmatory of BAF. The bronchial aspirate in this patient cultured Mycobacterium tuberculosis .
Radiological Features
Although BAF is a bronchoscopic diagnosis, imaging often provides the initial diagnostic
clue as this clinical entity has diverse but characteristic radiological manifestations.[10 ],[12 ],[13 ] The radiological findings in BAF comprise primary imaging features per se due to BAF itself while secondary imaging characteristics are due to the presence
of associated disease conditions.
Radiological features such as multifocal bronchial narrowing and peribronchial cuffing
are characteristic of BAF and can be considered as primary imaging features, while
collapse, consolidation, and mass lesions could be due to associated conditions.[10 ],[13 ] The associated clinical conditions such as pulmonary tuberculosis, chronic obstructive
pulmonary disease (COPD), pneumonia, and malignancy contribute to the radiological
picture.[1 ] Although studies on BAF [9 ],[12 ],[13 ] have included radiological aspects, however, a detailed description of the imaging
pattern in patients with BAF is yet to receive the attention that it deserves. This
pictorial essay highlights the spectrum of radiological appearances of BAF.
Airway involvement
Multifocal bronchial narrowing
This characteristic feature, when seen on HRCT, is often considered to be the diagnostic
hallmark of BAF.[1 ],[5 ],[10 ],[11 ] Bronchial narrowing [Figure 2 ] in patients with BAF tends to be multifocal in nature and usually involves right
middle and upper lobe bronchi. BAF affects the segmental or lobar bronchi with sparing
of trachea and the main bronchus in most of the patients. This is in stark contrast
with pattern of bronchostenosis seen in endobronchial tuberculosis where the main
and lobar bronchi are involved in a contiguous fashion. Pigmentary deposits in BAF
are usually encountered at the branching points within the tracheobronchial tree and
are followed by inflammatory response and bronchial stenosis.[13 ],[14 ] A CT-based study in 58 patients with BAF reported multifocal bronchial stenosis
in 23 (39.7%) with right middle lobe bronchus being most commonly affected.[13 ] In a recent prospective study from India, of the 80 patients with long-standing
history of exposure to biomass fuel smoke, 60 consented to undergo FOB, 24 (40%) of
whom were diagnosed with BAF, 17 (28.3%) had bronchial anthracosis only, while 19
(31.7%) had normal bronchial tree appearance. Five (20.8%) of the 24 patients with
BAF had multifocal bronchial narrowing on HRCT.[10 ] All 60 patients evaluated by Pilaniya et al .[10 ] happened to be females.
Figure 2: High-resolution computed tomography (HRCT) of chest (lung window) showing
multifocal narrowing of the left upper lobe bronchus (white arrow) in a 75-year-old
female with long-standing biomass fuel smoke exposure. FOB confirmed BAF involving
left upper lobe bronchus
Peribronchial cuffing
Peribronchial soft-tissue thickening/cuffing [Figure 3 ] on HRCT, in an appropriate setting, can raise suspicions of BAF.[13 ] However, this radiological feature is also thought to be suggestive of pulmonary
sarcoidosis.[15 ] Kahkouee et al .[13 ] have suggested that this feature occurs due to “the encroachment of anthracotic
deposits on airways, even in the absence of apparent tuberculosis or other lung diseases,
which may produce central peribronchial soft tissue thickening or intraparenchymal
peribronchial cuffing.” Furthermore, this may lead to the development of bronchial
narrowing or lobar/segmental atelectasis. Chung et al .[5 ] had reported peribronchial cuffing on CT chest in 24 of 28 patients with BAF. In
a series of 333 patients with BAF from Korea,[9 ] peribronchial cuffing was present in 80% while a study from Iran [13 ] documented it in 37 of 58 (63.1%) patients. In contrast, only 5 of the 24 patients
with BAF from India had peribronchial soft tissue cuffing.[10 ]
Figure 3: HRCT of the chest (lung window) showing peribronchial cuffing of right upper
lobe bronchus (white arrow) in a 62-year-old female diagnosed with BAF
Bronchiectasis
Bronchiectasis on HRCT [Figure 4 ] is not an uncommon finding in patients with BAF. Biomass fuel smoke acts as a chronic
irritant in the airways. This leads to chronic airway inflammation, goblet cell hypertrophy,
and mucous production. In addition, impairment of mucociliary escalator mechanism
occurs due to exposure to biomass fuel smoke.[16 ] All these factors predispose to the development of bronchiectasis in patients with
biomass fuel smoke exposure leading to BAF. In an earlier study from Korea,[12 ] bronchiectasis was reported in 30% of patients, while a study from Iran [13 ] documented it in 24 of 58 (41.3%) patients. Of the 58 patients, multilobar bronchiectasis
was seen in nine (15.5%) with the lingula being most commonly affected.[13 ] Three of the 24 patients from India with BAF had bronchiectasis on HRCT.[10 ]
Figure 4 (A and B): (A) Chest radiograph (PA view) in a 58-year-old female with BAF
showing crowding of bronchovascular markings in bilateral lower zones and cystic shadows
in left lower zone. (B) HRCT of chest (lung window) of the same patient showing bilateral
lower lobe fusiform bronchiectasis (more in left lower lobe when compared with right)
with thick fibrotic bands in the left lower lobe
Parenchymal involvement
Collapse
Lobar or segmental collapse is a common radiological finding in patients with BAF.
Collapse may be due to bronchostenosis/obstruction or extrinsic compression of the
affected bronchi. Although all lobes can be involved, the right middle lobe is most
commonly affected and often presents as an MLS [Figure 5 ]. This striking radiological presentation raises the suspicion of BAF in an appropriate
clinical setting.[1 ],[10 ] Right upper lobe collapse is not infrequently seen. Lobar or segmental collapse
is usually evident on chest radiograph with characteristic radiological signs [Figure 6 ]. Although the Golden S sign is classically described in patients with bronchial
carcinoma, it can also occur due to metastasis, primary mediastinal tumor, or enlarged
lymph nodes. In patients with BAF, Golden S sign can occur either due to bronchial
stenosis and complete obstruction or extrinsic compression by enlarged lymph nodes.[17 ] However, distinct anatomical characterization of lobar/segmental collapse is possible
on HRCT chest. In an earlier study on CT features in patients with BAF, segmental
collapse distal to the “smoothly narrowed bronchus” was the most common finding.[12 ] Lobar/segmental collapse usually raises a suspicion of malignancy in these patients
as BAF with concomitant adenocarcinoma has also been reported [Figure 7 ]. It is imperative for the pulmonologists/radiologists to exclude malignancy and/or
pulmonary tuberculosis in those patients who present with a visible collapse on imaging.[18 ] In the recent prospective series of 24 patients with BAF, segmental collapse was
seen in 13 patients.[10 ]
Figure 5 (A-C): (A) Chest radiograph (PA view) in a 54-year-old female with 30 years
history of biomass fuel smoke exposure showing an ill-defined opacity in the right
lower zone abutting the right cardiac margin suggestive of middle lobe syndrome (MLS).
(B) Chest radiograph (lateral view) of the same patient showing a wedge-shaped opacity
(black arrowheads) extending in an anteroinferior direction from the hilum to the
anterior chest wall suggestive of MLS. (C) HRCT of chest (lung window) showing a trapezoidal
opacity with its base toward hilum and contiguous with the right cardiac border confirming
the presence of MLS. FOB revealed anthracofibrosis of right middle lobe and bronchial
aspirate cultured Mycobacterium tuberculosis
Figure 6: Chest radiograph showing the characteristic golden S sign (white arrowheads)
suggestive of collapse of right upper lobe in a 65-year-old female. FOB confirmed
BAF of right upper lobe associated with tuberculosis
Figure 7: HRCT of chest showing segmental collapse of right middle and lower lobe
bronchi (white arrowheads) along with mass-like lesion in left lower lobe (black arrow)
in a 62-year-old female with BAF involving right upper and middle lobes and left lower
lobe. Transbronchial biopsy confirmed adenocarcinoma
The right middle lobe syndrome
MLS still continues to fascinate clinicians with its characteristic radiological presentation.
It has been postulated that middle lobe is prone to recurrent collapse due to (a)
lack of collateral ventilation leading to its anatomical isolation, (b) sharp angular
take-off of the middle lobe bronchus, and (c) extrinsic compression by enlarged lymph
nodes. Impaction of carbon particles present in the smoke occurs at the site of bronchial
bifurcation especially around right middle lobe orifice leading to anthracotic pigmentation.
Subsequently, inflammatory response results in fibrosis and stenosis of the affected
bronchus.[10 ],[11 ]
The index case of BAF in India,[11 ] a 65-year-old female with concomitant pulmonary tuberculosis, too presented radiologically
as MLS. On chest radiograph, MLS appears as an ill-defined opacity in the right middle
and lower zones with loss of cardiac silhouette on posteroanterior view [Figure 5 ]A, while on the lateral view, it is visualized as a wedge-shaped opacity extending
anteroinferiorly from the hilum [Figure 5 ]B. The diagnosis of MLS is confirmed on HRCT chest [Figure 5 ]C.[19 ] Six (25%) of our 24 patients with BAF presented as an MLS on chest imaging.[13 ]
Consolidation
Consolidation, visible on chest radiograph, is not an uncommon finding in patients
with BAF. This clinical entity is associated with pneumonia in nearly one-fourth of
patients and consolidation in BAF is usually due to associated pneumonia.[1 ] BAF is characterized by the presence of bronchial narrowing and a majority of consolidations
are seen in lobes having bronchial narrowing. The structural abnormality of the bronchus
is the major predisposing factor for the development of pneumonia in patients with
BAF.[1 ] Consolidation can be either lobar in nature [Figure 8 ] or multilobar involving multiple lobes [Figure 9 ]. The presence of consolidation with air bronchograms in patients with BAF usually
points toward a diagnosis of associated pneumonia [Figure 10 ] or tuberculosis. In a study from Iran,[13 ] consolidation on HRCT chest was seen among 32 of 58 (55.2%) patients with BAF with
right middle lobe being most commonly involved. Multilobar consolidation was seen
in 12 of 32 (37.5%) patients.[13 ] The index case of BAF reported from India [11 ] too had consolidation of the right middle lobe along with air bronchogram. Consolidation
seen on HRCT was observed in 13 of 24 (54.2%) patients with BAF.[10 ]
Figure 8: HRCT of chest (lung window, coronal view) showing lobar consolidation with
air bronchogram (black arrowheads) involving right lower lobe in a 70-year-old female.
FOB confirmed the diagnosis to be BAF
Figure 9: HRCT of chest (lung window) showing multilobar consolidation in bilateral
lower lobes with air bronchogram (black arrow). Visualization on FOB confirmed the
presence of BAF in the right upper and middle lobe bronchi. Bronchial aspirate cultured
M. tuberculosis while transbronchial biopsy was suggestive of caseating granulomas
Figure 10: HRCT of chest (lung window) in a 66-year-old female showing consolidation
in bilateral lower lobe with presence of air bronchograms (black arowheads). FOB visualized
BAF involving right upper and both lower lobe bronchi while bronchial aspirate cultured
Pseudomonas aeroginosa
Mass lesion
Usually most mass lesions in patients with BAF tend to be benign; however, all efforts
must be made to rule out malignancy in these patients. CT-guided transthoracic biopsy
and FOB are the most common modalities used to establish a diagnosis in patients with
BAF and associated mass lesion. The presence of irregular margins, spiculations, and
cavitation increases the possibility of malignancy [Figure 11 ]. Compared with other parenchymal opacities, mass lesions are a less common HRCT
finding and have been documented in 7 of 27 patients with BAF from Iran.[13 ] Mass lesions associated with cavitation were seen in 3 of our 24 (12.5%) patients
with BAF. Adenocarcinoma was confirmed in two of these patients.[10 ]
Figure 11: HRCT of chest (lung window, coronal view) in an 80-year-old female with
BAF showing multiple discrete nodules involving right upper lobe and both lower lobes
along with a mass lesion with irregular margins in left lower lobe (black arrow).
Transbronchial biopsy from left lower lobe was suggestive of adenocarcinoma
Parenchymal fibrotic bands
Parenchymal fibrotic bands on HRCT are not uncommon in patients with BAF. These appear
as linear opacities about 1–3 mm in thickness and usually extending up to the visceral
pleura [Figure 12 ]. It represents pleuroparenchymal fibrosis and has been documented in nearly 53%
of patients with BAF.[13 ] These bands represent areas of fibrosis caused due to exposure to biomass fuel smoke.
This leads to activation of pulmonary fibroblasts and an increased production of fibronectin,
and thus pleuroparenchymal fibrosis ensues. Parenchymal bands on HRCT were observed
in 11 of the 24 (45.8%) patients with BAF.[10 ]
Figure 12: HRCT of chest (lung window, coronal view) in a 56-year-old female with
BAF showing a curvilinear fibrotic opacity in the right upper lobe extending peripherally
upto the pleura (white arrowheads) suggestive of parenchymal fibrotic bands
Emphysema
Biomass fuel smoke exposure is a risk factor for development of both COPD and BAF.[1 ] Emphysema, both centrilobular and paraseptal [Figure 13 ], is often seen on HRCT in these patients. The presence of emphysema usually indicates
coexistence of COPD as an associated condition. In a series of 333 patients with BAF
from Korea, COPD was seen in 56 (16.8%) patients.[9 ] On HRCT, emphysema was detected in 4 (16.7%) of our 24 patients.[10 ]
Figure 13 (A and B): (A) Chest radiograph (PA view) in a 62-year-old female with 30
years history of biomass fuel smoke exposure and BAF showing bilateral hyperinflated
lung fields. (B) HRCT of chest (lung window) of the same patient showing bilateral
areas of centrilobular and paraseptal emphysema with upper lobe predominance. In addition,
she was diagnosed with chronic obstructive pulmonary disease
Interstitial pattern
Interstitial involvement in patients with BAF manifests as nodular or reticulonodular
opacities on chest radiograph [Figure 14 ]A. BAF associated with interstitial lung disease has previously been reported in
literature with four reports documenting seven patients,[20 ],[21 ],[22 ],[23 ] three of whom were reported from India.[22 ],[23 ] In a Korean study [20 ] of 114 patients with BAF, 1 patient had a usual interstitial pneumonia (UIP) pattern;
while in a Turkish study,[21 ] of the 27 patients with BAF, the authors documented the presence of an “interstitial
pattern” on chest CT in three patients, but detailed imaging description was not mentioned.
The studies from India reported UIP pattern [Figure 14 ]B in one patient; while in another two patients, a non-specific interstitial pneumonia
pattern was seen [Figure 14 ]C.[24 ]
Figure 14 (A-C): (A) Chest radiograph (PA view) showing bilateral basilar reticulonodular
opacities along with evidence of volume loss and cardiomegaly in a 76-year-old female
who presented with exertional dyspnoea. FOB revealed BAF. (B) HRCT of chest (lung
window) in a 76-year-old male with biomass fuel smoke exposure showing extensive bilateral
basal honeycombing, reticulations, and subpleural fine fibrosis suggestive of usual
interstitial pneumonia pattern. FOB revealed BAF. (C) HRCT of chest (lung window)
of a 65-year-old female showing bilateral areas of ground-glass opacities along with
interlobular septal thickening, peribronchial cuffing, and traction bronchiectasis
in right lower lobe suggestive of non-specific interstitial pneumonia pattern. Right
upper lobe BAF was visualized on FOB
Ground-glass, mosaic appearance, and nodules
On HRCT, patients with BAF may present with ground-glass opacities [Figure 15 ]A and [Figure 15 ]B, mosaic appearance [Figure 15 ]B, micro- and macronodules as well as tree-in-bud opacities [Figure 16 ]. Exposure to biomass fuel smoke is a risk factor for bronchiolitis in these patients,
which manifests radiologically as centrilobular nodules as well as mosaic appearance.
These represent inflammatory changes, small airways obstruction, and areas of air
trapping.[16 ] In addition, solitary and multiple nodules too may be seen on HRCT. Cavitating nodules
[Figure 17 ], when present, usually point toward a diagnosis of malignancy. In a study from Iran,[13 ] mosaic appearance was seen in 21 of 58 (36.2%) patients on HRCT. In the same study,
solitary and multiple pulmonary nodules were less commonly reported in 11 of 58 and
8 of 58 patients, respectively. In a series of 24 patients from India by Pilaniya
et al .,[10 ] mosaic attenuation was documented in 5, while nodular lesions and tree-in-bud opacities
were present in 1 patient each.
Figure 15 (A and B): (A) Chest radiograph (PA view) showing bilateral basilar reticulonodular
opacities in a 68-year-old female with a 50-year history of biomass fuel smoke exposure.
In addition, extensive calcification of the tracheal wall is also noted. (B) HRCT
of chest (lung window) of the same patient showing extensive ground glass opacities
and mosaic appearance consistent with small airway narrowing suggestive of bronchiolitis
along with extensive calcification of the tracheal wall
Figure 16: HRCT in a 58-year-old male showing centrilobular nodules and “tree-in-bud”
opacities in posterior segment of right upper lobe (white arrow). Along with BAF,
FOB visualized caseous material in right upper lobe bronchus suggestive of endobronchial
tuberculosis
Figure 17: HRCT of chest (lung window) in an 80-year-old female BAF showing multiple
discrete nodules involving right upper and both lower lobes with cavitation (white
arrowheads). Transbronchial biopsy confirmed diagnosis to be of adenocarcinoma, while
FOB suggested anthracofibrosis in left upper lobe
Mediastinal adenopathy
BAF can at times present with mediastinal lymphadenopathy on HRCT chest.[9 ],[12 ],[13 ] Enlarged mediastinal lymph nodes may develop calcification within them [Figure 18 ]. The presence of heterogeneous density (necrotic material) within enlarged lymph
nodes usually suggests tuberculosis. These lymph nodes can cause extrinsic bronchial
compression leading to lobar/segmental atelectasis.[1 ],[5 ],[12 ] In addition, these can erode into the bronchus and subsequently lead to bronchostenosis.[5 ],[12 ] In a study from Korea, enlarged lymph nodes were seen in 166 of 252 (66%) patients,
of whom 112 had calcification within the nodes.[12 ] In a recent clinico-radiological prediction model for BAF from Korea, lymph node
enlargement and calcification were important diagnostic predictors along with age
>70 years, female gender, and active tuberculosis. Other radiological findings such
as atelectasis, stenosis, and bronchial wall thickening too were considered to be
important predictors of BAF.[25 ] In a CT-based study from Iran, enlarged mediastinal and peribronchial lymph nodes
were detected in 56 of 58 (96.5%) and 46 of 58 (79.3%) patients, respectively.[13 ] Increasing use of endobronchial ultrasound (EBUS) guidance has led to increased
detection of mediastinal nodes on bronchoscopy and would be of help in confirming
nodes with anthracotic pigmentation. In a retrospective study from India, of the 300
patients with mediastinal adenopathy who underwent EBUS, 17 had cytopathological evidence
of anthracosis, 2 of whom were diagnosed with tuberculosis. These patients had visual
evidence of BAF on FOB. EBUS-guided fine-needle aspirate from these lymph nodes revealed
black particulate matter or even in some cases “black tarry thick liquid.”[26 ] It is postulated that mediastinal lymphadenopathy with calcification is due to inhaled
carbon particles present in the biomass fuel smoke which are then phagocytosed by
the pulmonary macrophages leading to deposition in the lymphatic tissue. In addition,
silica present in the smoke induces parenchymal fibrosis and calcification of the
lymph nodes.[1 ],[5 ]
Figure 18: Contrast-enhanced CT of chest (mediastinal window) showing calcified subcarinal
(black arrow) and left hilar lymph node (white arrowhead) in a 73-year-old female
with BAF involving right middle lobe
Pleural involvement
Pleural involvement in patients with BAF is usually a part of an associated disease
process such as tuberculosis or malignancy. This usually manifests as pleural effusion
or pleural thickening. A high index of suspicion for pulmonary tuberculosis should
always be kept in mind in a patient with BAF presenting with pleural effusion [Figure 19 ]. In a study on HRCT findings in patients with BAF, pleural effusion was seen in
17 of 58 (29.3%) patients while pleural thickening was reported in 14 of 58 (24.1%)
patients.[13 ] In the series by Chung et al .,[5 ] pleural effusion was seen in 4 of 28 patients.
Figure 19: Contrast-enhanced CT of chest (mediastinal window) in a 70-year-old female
with 40 years history of biomass fuel smoke exposure and right lower lobe BAF showing
left-sided pleural effusion. Bronchial aspirate cultured Mycobacterium tuberculosis
Radiological features of BAF associated with tuberculosis
Pulmonary tuberculosis, seen in a third of patients with BAF, is now considered to
be an associated condition rather than a causative factor. BAF associated with tuberculosis
has a distinct radiological presentation.[18 ] HRCT findings in these patients include consolidation both lobar and multifocal
[Figure 9 ], cavitation, “tree-in-bud” nodules [Figure 16 ], mediastinal adenopathy, and pleural involvement [Figure 19 ].[27 ] On contrast-enhanced CT chest, these mediastinal lymph nodes frequently show contrast
enhancement with heterogeneous densities suggestive of areas with necrosis. Dhamija
et al .[26 ] reported that 17 of 300 patients with mediastinal adenopathy who underwent EBUS
had visual evidence of BAF, 2 of whom were culture-positive for M. tuberculosis. Transbronchial
or EBUS-guided needle aspirations from these nodes show anthracotic pigment-laden
macrophages, areas of necrosis, and granulomas.[26 ]
Conclusion
The diagnosis of BAF can only be established on bronchoscopic visualization of anthracotic
pigmentation along with narrowing/distortion of the affected bronchus. Biomass fuel
smoke exposure is a common risk factor for the development of COPD and BAF. If no
further investigations are done, these patients would continue to be treated as COPD
and the diagnosis of BAF would be overlooked. Since most patients are reluctant to
undergo bronchoscopy, an invasive procedure, a diagnosis of BAF often remains unconfirmed.
Although associated conditions such as tuberculosis, COPD, pneumonia, and malignancy,
when present, can confound the radiological picture, HRCT may still provide the initial
diagnostic clues in an appropriate clinically setting. Imaging by proving the initial
clue also helps decision-making and facilitates bronchoscopy. Multifocal bronchial
narrowing, when present on HRCT, is the most characteristic feature of BAF.[1 ],[3 ] In addition, peribronchial cuffing and mediastinal lymphadenopathy too can be considered
as diagnostic predictors of BAF.[25 ]
There is a need to focus on the development of noninvasive techniques for an early
diagnosis of BAF and to evolve appropriate treatment strategies. Currently, it appears
that a preventive approach remains the only means of reducing morbidity and mortality
by highlighting the perilous consequences of biomass fuel smoke exposure, especially
in developing countries.
Acknowledgements
The authors are grateful to Dr Shruti Mittal, Junior Resident, Department of Radiodiagnosis,
Maulana Azad Medical College and associated Lok Nayak Hospital for her help with the
imaging.
