the term  pneumoconiosis  was coined by zenker to define a group of diseases caused by inhalation of dust . silicosis is a fibrosing disease of the lung caused by the inhalation , retention , and pulmonary reaction to crystalline silica . silicosis is known to cause random nodules , progressive massive fibrosis ( pmf ) , and obstructive airway disease . anthracosis or coal workers ' pneumoconiosis is seen in coal workers and is caused by inhalation and deposition of black pigments of which carbon is a major constituent . air pollution , biomass smoke , and cigarette smoke are also known to cause deposition of black pigment leading to environmental anthracosis . environmental anthracosis usually leads to anthracofibrosis ( anthracosis with bronchial narrowing ) and obstructive airway disease . but anthracosilicosis , a form of mixed dust pneumoconiosis , has not been reported due to nonoccupational cause . we present six cases of nonoccupational anthracofibrosis / anthcosilicosis from ladakh in jammu and kashmir , india . six cases from the ladakh region in jammu and kashmir ( india ) that presented to a tertiary care institute in delhi from january 2012 to july 2015 with similar clinico - radiological - pathological features were analyzed . of these six cases , four were analyzed from the available records and two were analyzed prospectively . a 58-year - old nonsmoker lady had presented with breathlessness on exertion and cough with melanoptysis for 5 years . there was no significant past history except having taken antitubercular therapy 3 years ago for the same complaints with no improvement in the symptoms . on examination , the available computed tomography ( ct ) of the chest showed partially calcified bilateral uppers lobe masses , air trapping , and random nodules all over the lung fields [ figure 1b  d ] . on comparison of two ct scans , the masses had increased by 7 mm on the right side and 6 mm on the left side . the spirometry showed forced vital capacity ( fvc ) of 1.43 lit ( 67% predicted ) , forced expiratory volume in the 1 second ( fev1 ) of 1.10 lit ( 62% predicted ) with fev1/fvc of 0.77 . bronchoscopy had shown narrowing of both the upper lobe bronchi and distortion of the bronchial tree with deposition of anthracotic pigments throughout the bronchial tree [ figure 2a  c ] . transbronchial lung biopsy ( tblb ) showed nodular aggregates of polygonal cells with abundant black pigment in the cytoplasm . there was a suspicion of melanoma ; hence , immunohistochemistry ( ihc ) was performed . ihc was positive for cd68 while negative for cd56 , hmb-45 , and ki , and hence , melanoma was ruled out . a final diagnosis of anthracofibrosis was made , as polarized light microscopy , which is pathognomonic of silicosis had not been performed in this case . ( case 1 ) : a ) chest radiograph showing bilateral reticulonodular opacities , upper lobe fibroparenchymal lesion and heterogenous opacity in left mid zone . b ) ct chest showing partially calcified soft tissue mass in the right upper lobe 3458 mm ( shown by arrow ) and left upper lobe ( 3551 mm ) . c ) fibrotic changes seen in both upper lobes d ) randomly distributed nodules in bilateral lung ( case 1 ) : ( a and c ) bronchoscopy showing deposition of anthracotic pigments thought out bronchial tree on both sides and narrowing upper lobe bronchi due to b ) external compression with distortion of bronchial lumen . stroma was made up of fibrocollagenous tissue with neutrophils and mononuclear cells consistent diagnosis of anthracosis a 57-year - old nonsmoker lady from ladakh in jammu and kashmir , india had presented with breathlessness on exertion and minimal cough for 23 years with occasional history of wheezing . there was also history of antitubercular treatment 910 years ago for 9 months . on examination , the chest radiograph showed reticulonodular opacities with right upper lobe collapse [ figure 3a ] . the ct showed an ill - defined mass - like lesion in the right hilum with air trapping and multiple random nodules scattered in both the lung fields [ figure 3b  d ] . the spirometry showed fvc of 2.36 lit ( 105% predicted ) , fev1 of 0.99 lit ( 53% predicted ) , fev1/fvc - 0.42 . both the right and left bronchial anatomies were distorted , with mucosal edema and anthracotic pigment . the bronchoscope could not be negotiated into the right intermedius bronchus due to distorted anatomy . whole body positron emission tomography ( pet)-ct scan showed confluent lymph nodes with increased fluorodeoxyglucose ( fdg ) uptake in the right hilum [ table 1 ] . as per the records , she was being followed up for 2 years and treated with inhaled bronchodilator . the spirometry had shown improvement in fvc by 760 ml and fev1 by 720 ml . after 2 years a repeat bronchoscopy , ct scan chest , and pet scan had also been performed . there was no significant change in ct scan , bronchoscopy , and pet scan compared to previous reports . a diagnosis of anthracofibrosis was made on the basis of nonprogressive lesions , bronchoscopy , and histopathology . ( case 2 ) : a ) chest radiograph showing reticulo - nodular opacities in bilateral lung with segmental collapse of right upper lobe . b ) ct chest showing ill - defined mass lesion of ( 3.22.7 cm ) in right hilum encasing the right upper lobe bronchus causing an abrupt cut off . d ) multiple randomly distributed nodules scatted in both lungs a 62-year - old old nonsmoker lady had presented with breathlessness on exertion of 5 years and cough with minimum sputum for 23 years . on examination , the ct had shown speculated mass lesion in the apical segments of the right upper lobe with air trapping and random nodules [ figure 4b  d ] . the spirometry had shown fvc of 1.99 lit ( 84% predicted ) , fev1 of 1.35 lit ( 69% predicted ) with fev1/fvc of 0.68 . bronchoscopy had shown constriction and deposition of anthracotic pigments in the right upper lobe bronchus . whole body pet - ct scan showed an increased fdg uptake in the lung lesions and lymph nodes . transthoracic lung biopsy of the lung mass was performed , which showed necrosis and anthrocotic pigment deposition consistent with anthracofibrosis . the sample was not subjected to polarized light and hence , a final diagnosis of anthracofibrosis was made . ( case 3 ) : a ) chest radiograph showing bilateral small nodular opacities in all zones with one heteogenous opacity in right upper lobe . ( c and d ) multiple randomly distributed nodules scatted in bilateral lung field a 55-year - old nonsmoker lady had presented with dyspnea on exertion and cough with melanoptysis for the last 56 years . there was history of bronchodilator therapy for 3 years with some improvement in the symptoms . on examination , the ct of the chest showed an irregular soft tissue mass in both the upper lobes with random nodules in both the lungs [ figure 5b  d ] . the spirometry showed fvc of 2.75 lit ( 131% predicted ) , fev1 of 1.49 lit ( 85% predicted ) , and fev1/fvc of 0.54 . the diffusion capacity for carbon monoxide ( dlco ) was -1.73 ml / kg / min ( 102% predicted ) . bronchoscopy showed extensive anthracotic pigments scattered throughout the bronchial tree with complete occlusion of the left upper division with mass - like lesion [ figure 6a and b ] . bronchial biopsy was inconclusive ; hence , trucut transthoracic lung biopsy was performed , which showed a tumor of polygonal and spindle cells . a suspicion of malignant melanoma hence , a repeat biopsy was performed , which showed features of anthracosis [ figure 6c ] and deposition of silicotic pigment ( polarizing birefringent - positive ) [ figure 6d ] . ( case 4 ) : a ) chest radiograph showing reticulo - nodular opacities in bilateral lung with fibrotic lesion on right parahilar region with mediastinal widening . b ) ct chest showing irregular soft tissue ( 3  2.8  2.6 cm ) mass with speculated margin , calcification and collapse of left upper lobe . d ) multiple tiny random nodules were scattered in both lungs ( case 4 ) : a ) bronchoscopy showing extensive anthracotic pigments deposition throughout the bronchial tree of both sides ( a ) with complete occlusion of left upper division with mass like lesion and b ) distortion of bronchial lumen . c ) biopsy showing alveolar septae thicken due to infiltration of numerous polygonal and spindle cell with large amount of black ( anthracotic ) pigment . d ) the fibrous tissue was heavily infiltrated with silicotic pigment deposition ( polarizing birefregent positive ) a 42-year - old nonsmoker lady was investigated by the local physician with chest radiograph , ct scan of the thorax , and other routine investigation , and diagnosed to have left lower lobe hydatid cyst . the ct showed diffuse fine nodules in both the lung fields , with a left lower lobe hydatid cyst [ figure 7b  d ] . the spirometry showed fvc of 2.94 lit ( 105% predicted ) , fev1 of 2.33 lit ( 93% predicted ) with fev1/fvc 0.76 . she was treated with oral albendazole 10 mg / kg per day and planned for surgery of hydatid cyst . video - assisted thoracoscopy with excision of the hydatid cyst was performed and simultaneous biopsy was taken from the lung parenchyma . apart from hydatid cyst , the lung biopsy showed anthracotic and polarizing birefringent pigment deposition [ figure 8a and b ] , suggestive of anthracosilicosis . ( case 5 ) : a ) chest radiograph showing bilateral small nodular opacities in all zones with well , defined circular heterogeneous opacity in left lower lobe para and retrocardiac region . cect chest showing b ) well defined cavity containing soft tissue density in posterior basal segment of left lower lobe and ( c and d ) randomly distributed fine nodules involving bilateral lung parenchyma ( case 5 ) : a ) lung biopsy showing fibrous exudate , macular patches around the bronchovascular bundle , circumscribed necrotic area with anthracotic and b ) polarizing birefregent pigment deposition a 62-year - old nonsmoker lady presented with breathlessness on exertion , chest pain , and cough with on - and - off melanoptysis for 1 year . on examination , the ct showed multiple centrilobular nodules scattered in both the lungs with fibroparenchymal changes and air trapping [ figure 9b ] . the spirometry showed fvc of 1.54 lit ( 63% predicted ) , fev1 of 1.22 lit ( 60% predicted ) with fev1/fvc of 0.79 . bronchoscopy showed anthrocotic pigments deposition in both sides with distortion of the bronchial mucosa [ figure 9c and d ] . bronchial biopsy showed nonspecific changes in the bronchial mucosa with anthracotic and silicotic pigment depositions . ( case 6 ) : a ) chest radiograph showing bilateral small nodular opacities in all zones with fibroparenchymal changes with pleural thickening . b ) cect chest showing randomly distributed nodules scatted in bilateral lung fields with fibroparenchymal changes and pleural reaction . ( c and d ) bronchoscopy showing anthracotic pigments deposition throughout bronchial tree of both sides with luminal distortion a 58-year - old nonsmoker lady had presented with breathlessness on exertion and cough with melanoptysis for 5 years . there was no significant past history except having taken antitubercular therapy 3 years ago for the same complaints with no improvement in the symptoms . on examination , the available computed tomography ( ct ) of the chest showed partially calcified bilateral uppers lobe masses , air trapping , and random nodules all over the lung fields [ figure 1b  d ] . on comparison of two ct scans , the masses had increased by 7 mm on the right side and 6 mm on the left side . the spirometry showed forced vital capacity ( fvc ) of 1.43 lit ( 67% predicted ) , forced expiratory volume in the 1 second ( fev1 ) of 1.10 lit ( 62% predicted ) with fev1/fvc of 0.77 . bronchoscopy had shown narrowing of both the upper lobe bronchi and distortion of the bronchial tree with deposition of anthracotic pigments throughout the bronchial tree [ figure 2a  c ] . transbronchial lung biopsy ( tblb ) showed nodular aggregates of polygonal cells with abundant black pigment in the cytoplasm . there was a suspicion of melanoma ; hence , immunohistochemistry ( ihc ) was performed . ihc was positive for cd68 while negative for cd56 , hmb-45 , and ki , and hence , melanoma was ruled out . transthoracic trucut biopsy was consistent with anthracosis [ figure 2d ] . a final diagnosis of anthracofibrosis was made , as polarized light microscopy , which is pathognomonic of silicosis had not been performed in this case . ( case 1 ) : a ) chest radiograph showing bilateral reticulonodular opacities , upper lobe fibroparenchymal lesion and heterogenous opacity in left mid zone . b ) ct chest showing partially calcified soft tissue mass in the right upper lobe 3458 mm ( shown by arrow ) and left upper lobe ( 3551 mm ) . c ) fibrotic changes seen in both upper lobes d ) randomly distributed nodules in bilateral lung ( case 1 ) : ( a and c ) bronchoscopy showing deposition of anthracotic pigments thought out bronchial tree on both sides and narrowing upper lobe bronchi due to b ) external compression with distortion of bronchial lumen . stroma was made up of fibrocollagenous tissue with neutrophils and mononuclear cells consistent diagnosis of anthracosis a 57-year - old nonsmoker lady from ladakh in jammu and kashmir , india had presented with breathlessness on exertion and minimal cough for 23 years with occasional history of wheezing . there was also history of antitubercular treatment 910 years ago for 9 months . on examination , the chest radiograph showed reticulonodular opacities with right upper lobe collapse [ figure 3a ] . the ct showed an ill - defined mass - like lesion in the right hilum with air trapping and multiple random nodules scattered in both the lung fields [ figure 3b  d ] . the spirometry showed fvc of 2.36 lit ( 105% predicted ) , fev1 of 0.99 lit ( 53% predicted ) , fev1/fvc - 0.42 . both the right and left bronchial anatomies were distorted , with mucosal edema and anthracotic pigment . the bronchoscope could not be negotiated into the right intermedius bronchus due to distorted anatomy . whole body positron emission tomography ( pet)-ct scan showed confluent lymph nodes with increased fluorodeoxyglucose ( fdg ) uptake in the right hilum [ table 1 ] . as per the records , she was being followed up for 2 years and treated with inhaled bronchodilator . the spirometry had shown improvement in fvc by 760 ml and fev1 by 720 ml . after 2 years a repeat bronchoscopy , ct scan chest , and pet scan had also been performed . there was no significant change in ct scan , bronchoscopy , and pet scan compared to previous reports . a diagnosis of anthracofibrosis was made on the basis of nonprogressive lesions , bronchoscopy , and histopathology . ( case 2 ) : a ) chest radiograph showing reticulo - nodular opacities in bilateral lung with segmental collapse of right upper lobe . b ) ct chest showing ill - defined mass lesion of ( 3.22.7 cm ) in right hilum encasing the right upper lobe bronchus causing an abrupt cut off . a 62-year - old old nonsmoker lady had presented with breathlessness on exertion of 5 years and cough with minimum sputum for 23 years . on examination , the ct had shown speculated mass lesion in the apical segments of the right upper lobe with air trapping and random nodules [ figure 4b  d ] . the spirometry had shown fvc of 1.99 lit ( 84% predicted ) , fev1 of 1.35 lit ( 69% predicted ) with fev1/fvc of 0.68 . bronchoscopy had shown constriction and deposition of anthracotic pigments in the right upper lobe bronchus . whole body pet - ct scan showed an increased fdg uptake in the lung lesions and lymph nodes . transthoracic lung biopsy of the lung mass was performed , which showed necrosis and anthrocotic pigment deposition consistent with anthracofibrosis . the sample was not subjected to polarized light and hence , a final diagnosis of anthracofibrosis was made . ( case 3 ) : a ) chest radiograph showing bilateral small nodular opacities in all zones with one heteogenous opacity in right upper lobe . a 55-year - old nonsmoker lady had presented with dyspnea on exertion and cough with melanoptysis for the last 56 years . there was history of bronchodilator therapy for 3 years with some improvement in the symptoms . on examination , the ct of the chest showed an irregular soft tissue mass in both the upper lobes with random nodules in both the lungs [ figure 5b  d ] . the spirometry showed fvc of 2.75 lit ( 131% predicted ) , fev1 of 1.49 lit ( 85% predicted ) , and fev1/fvc of 0.54 . the diffusion capacity for carbon monoxide ( dlco ) was -1.73 ml / kg / min ( 102% predicted ) . bronchoscopy showed extensive anthracotic pigments scattered throughout the bronchial tree with complete occlusion of the left upper division with mass - like lesion [ figure 6a and b ] . bronchial biopsy was inconclusive ; hence , trucut transthoracic lung biopsy was performed , which showed a tumor of polygonal and spindle cells . hence , a repeat biopsy was performed , which showed features of anthracosis [ figure 6c ] and deposition of silicotic pigment ( polarizing birefringent - positive ) [ figure 6d ] . ( case 4 ) : a ) chest radiograph showing reticulo - nodular opacities in bilateral lung with fibrotic lesion on right parahilar region with mediastinal widening . b ) ct chest showing irregular soft tissue ( 3  2.8  2.6 cm ) mass with speculated margin , calcification and collapse of left upper lobe . d ) multiple tiny random nodules were scattered in both lungs ( case 4 ) : a ) bronchoscopy showing extensive anthracotic pigments deposition throughout the bronchial tree of both sides ( a ) with complete occlusion of left upper division with mass like lesion and b ) distortion of bronchial lumen . c ) biopsy showing alveolar septae thicken due to infiltration of numerous polygonal and spindle cell with large amount of black ( anthracotic ) pigment . d ) the fibrous tissue was heavily infiltrated with silicotic pigment deposition ( polarizing birefregent positive ) a 42-year - old nonsmoker lady was investigated by the local physician with chest radiograph , ct scan of the thorax , and other routine investigation , and diagnosed to have left lower lobe hydatid cyst . the ct showed diffuse fine nodules in both the lung fields , with a left lower lobe hydatid cyst [ figure 7b  d ] . the spirometry showed fvc of 2.94 lit ( 105% predicted ) , fev1 of 2.33 lit ( 93% predicted ) with fev1/fvc 0.76 . she was treated with oral albendazole 10 mg / kg per day and planned for surgery of hydatid cyst . video - assisted thoracoscopy with excision of the hydatid cyst was performed and simultaneous biopsy was taken from the lung parenchyma . apart from hydatid cyst , the lung biopsy showed anthracotic and polarizing birefringent pigment deposition [ figure 8a and b ] , suggestive of anthracosilicosis . ( case 5 ) : a ) chest radiograph showing bilateral small nodular opacities in all zones with well , defined circular heterogeneous opacity in left lower lobe para and retrocardiac region . cect chest showing b ) well defined cavity containing soft tissue density in posterior basal segment of left lower lobe and ( c and d ) randomly distributed fine nodules involving bilateral lung parenchyma ( case 5 ) : a ) lung biopsy showing fibrous exudate , macular patches around the bronchovascular bundle , circumscribed necrotic area with anthracotic and b ) polarizing birefregent pigment deposition a 62-year - old nonsmoker lady presented with breathlessness on exertion , chest pain , and cough with on - and - off melanoptysis for 1 year . on examination , the vitals were within normal limits . the ct showed multiple centrilobular nodules scattered in both the lungs with fibroparenchymal changes and air trapping [ figure 9b ] . the spirometry showed fvc of 1.54 lit ( 63% predicted ) , fev1 of 1.22 lit ( 60% predicted ) with fev1/fvc of 0.79 . bronchoscopy showed anthrocotic pigments deposition in both sides with distortion of the bronchial mucosa [ figure 9c and d ] . bronchial biopsy showed nonspecific changes in the bronchial mucosa with anthracotic and silicotic pigment depositions . ( case 6 ) : a ) chest radiograph showing bilateral small nodular opacities in all zones with fibroparenchymal changes with pleural thickening . b ) cect chest showing randomly distributed nodules scatted in bilateral lung fields with fibroparenchymal changes and pleural reaction . ( c and d ) bronchoscopy showing anthracotic pigments deposition throughout bronchial tree of both sides with luminal distortion we have described six cases of nonoccupational anthracofibrosis / anthracosilicosis from the ladakh region of jammu and kashmir in north india . nonoccupational silicosis has been reported from various parts of the world including ladakh . in the study from ladakh , the presence of soot and silica was demonstrated in the environment of ladakh but the radiographic abnormality in the study was attributed to only silica . in fact , anthracosis and anthracofibrosis have been described from many parts of the country but not from ladakh . also , this is the first time that anthracosilicosis has been described in the nonindustrial population . in our study , we could demonstrate soot in 6/6 cases and both soot and silica in the pathological samples of only 3/6 cases . however , we believe that all the patients had anthracosilicosis because there is high predilection of silica exposure in the ladakh region in jammu and kashmir , india ( discussed later ) . also , these three cases where silica could not be demonstrated had pmf with random nodules , a finding common with silica dust but not with anthracofibrosis . ladakh in jammu and kashmir , india is among the highest of the world 's inhabited plateaus situated at > 10,000 feet above the sea level . this high altitude and geographic location of ladakh gives rise to the long duration of winter of nearly 45 months in years with sub - zero temperature . one of the reasons for anthracosilicosis may be exposure to soot from the burning of wood and dung in winter to keep the rooms warm . houses in ladakh have fireplaces in the center of room , which use partially burnt wood / dung with smoke during the noncooking period . people usually remain indoors during this prolonged harsh winter ; cooking is also usually done in the same room [ figure 10a ] . the windows are also very small and the houses lack chimneys [ figure 10b ] . women are exposed more to this smoke and soot compared to men because of cooking and indoor confinement . dust storm is common in ladakh mostly during spring season . during these storms a thick blanket of fine dust covers the affected villages , and inhabitants are exposed to considerable amounts of the dust for several days . the frequency , duration , and severity of these dust storms vary considerably from one village to another . in a study by norboo et al . , dust taken from the living rooms from one of the village 's houses had particles ranging from 0.55 m diameters and about half of it was silica . women are again more prone to exposure because they do most of the farming work , sweep the dusty houses , and carry baskets of earth for the traditional toilets . these unique environmental features make the population in ladakh , especially women , prone to nonoccupational anthracosilicosis . a ) roof and wall of the living room showing deposition of black soots and smoke particles . c ) new type of chula with chimmey using presently and old one nobroo et al . had mentioned about taking preventive measures in their study . in the last 30 years , a few preventive measures have been taken , i.e. some of the villages have switched over to electrical heating measures and chimneys have been installed in certain houses in the towns and cities [ figure 10c ] . however , preventive measures are still required . these are : awareness about environmental hygiene , education about installation of chimneys and exhaust fans in all the villages , and using noncombustive substance for cooking and heating in remote areas as well . a systemic study also needs to be undertaken in order to find out the exact role of silica and soot each and prevent this irreversible disease . on ct 4/6 cases showed mass lesions of > 3 cm size , i.e. , pmf with calcified mediastinal lymph nodes , which is one of the commonest lesions seen in complicated pneumoconiosis . in two of the cases ( cases 1 and 4 ) , an increase in the size of the mass lesion was demonstrated . pet scan of two of the patients ( cases 2 and 3 ) showed an increased fdg uptake as well . in two of the cases , even histopathology mimicked malignancy ( cases 1 and 4 ) . although increase in the size of the lesion , increased metabolic uptake and anthracotic pigments are known to occur in pmf , these findings can be mistaken for malignancy if the patient is not expected to have pmf . there were random nodules and centrilobular nodules in all the six cases , which might have been misdiagnosed as miliary or pulmonary tuberculosis . in this series , three out of six patients ( cases 1 , 2 , and 4 ) had received antituberculosis treatment possibly erroneously . increased awareness about environmental anthracosilicosis clinical finding , ct scan , and/or spirometry showed obstructive airway disease in all cases except for case 5 possibly because she was diagnosed incidentally early in the course of illness while undergoing investigation for hydatid . she would have had a similar fate after a few years , had she not been diagnosed and advocated the preventive measures . the obstructive abnormalities in other cases were possibly due to both soot and silica since both are known to cause obstructive airway disease . silica leads to obstructive airway disease because of inflammation of large and small airways with emphysema , whereas anthracosis leads to chronic bronchitis . the treatment of airway disease in these patients would go a long way in treating this on bronchoscopy , five cases showed multiple anthracotic pigments with narrowing and distortion of the bronchus , which is pathognomonic of anthracofibrosis . on histopathology , abundant black anthracotic pigment was present in all the cases that was suggestive of anthracosis . the presence of birefringent particles on polarized light microscopy , which is diagnostic of silicosis is essential when the role of environmental dust is not known . the earlier study reported from ladakh in jammu and kashmir , india did not correlate the environmental dust with pathological findings . so , though we have not accurately completed the unfinished work of sayeed et al . , it is an important step for inciting a prospective research in order to improve the environmental anomaly of this region . anthracosilicosis is a common finding among older female ladakh residents due to exposure to free silica and biomass fuel smoke in the environment . finally , environmental measures and a proper study need to be undertaken for knowing a relative role of silica versus soot in causing the lung disease and preventing this irreversible condition .
background : nonoccupational anthracosis and silicosis has been reported from various parts of the world including ladakh in jammu and kashmir , india ; however , anthracosilicosis has only been reported in industrial workers till date.materials and methods : six cases from the ladakh region in jammu and kashmir , india with similar clinico - radiological - pathological features , i.e. , anthracosilicosis / anthracofibrosis have been analyzed . 
 of these , four were analyzed retrospectively and two prospectively.result:all the patients were homemakers and resided in ladakh in jammu and kashmir , india since birth with an age range of 4262 years and an average age of 56 years . 
 their average duration of symptoms was 4 years . 
 spirometry showed small and/or large airway disease in 5/6 cases . on computed tomography ( ct ) , 4/6 cases showed progressive massive fibrosis ( pmf ) with calcified mediastinal lymph nodes . 
 there were random or centrilobular nodules in all the six cases . 
 bronchoscopy in 5/6 cases showed multiple anthracotic pigments with narrowing and distortion of the bronchus ( anthracofibrosis ) . 
 malignancy was suspected clinico - radiologically in four cases and pathologically in two cases . on histopathology , anthracosis was demonstrated in all and silicosis in three cases.conclusion:anthracosilicosis can occur due to environmental exposure . 
 ladakh in jammu and kashmir , india is the only place across the globe with unique environmental features having the presence of both free silica and biomass fuel . 
 the disease was observed predominantly in older women . 
 awareness would prevent unnecessary investigation for malignancy . 
 treatment with the bronchodilator is useful as it has evidence of airway disease . 
 finally , environmental measures and a proper study need to be undertaken for knowing the relative role of silica versus soot in causing the lung disease and preventing this irreversible condition .