Chronic obstructive pulmonary disease in smokers and never-smokers: Diagnostic traps and problems of differential diagnosis (clinical case report)

Introduction. Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality worldwide. The persistent clinical stereotype “COPD – smoker’s disease” leads to systematic diagnostic errors, especially among neversmokers, women, and elderly patients with comorbidities.

Aim. To systematize the main causes of misdiagnosis of COPD based on the analysis of clinical cases from forensic medical practice and to propose practical algorithms for its early detection.

Materials and methods. An analysis of international studies (PubMed, Scopus, Web of Science, 2000–2025) and GOLD 2025 clinical guidelines was performed. Additionally, materials from four forensic medical examinations (2021–2024) with fatal outcomes, where the diagnosis of COPD was established only at autopsy or its severity was underestimated, were analyzed.

Results. Four clinical cases are presented: a 65-year-old patient with severe COPD (GOLD IV) and central lung cancer; a 48-yearold patient with a misdiagnosis of bronchial asthma (at autopsy – bullous emphysema); an 86-year-old patient (never-smoker, biomass fuel exposure) with a clinical diagnosis of pneumonia and chronic heart failure; a 54-year-old patient with dermatomyositis-like rash treated for a systemic connective tissue disease (at autopsy – COPD). The key defect in all cases was the absence or incorrect interpretation of spirometry.

Conclusion. Post-bronchodilator spirometry remains the gold standard for COPD verification. Lack of response to standard therapy, asymmetry of respiratory excursion, skin manifestations, and yellow nail syndrome are red flags requiring extended differential diagnostic investigation. Assessment of alternative risk factors (biomass fuel, occupational hazards) is mandatory regardless of smoking status.

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