Although this case demonstrate the familiar imaging appearance of alpha₁-antitrypsin deficiency, the disease can have a range of imaging manifestations including upper-lobe-predominant emphysema and emphysema with cystic bronchiectasis.^1,2  Disease severity is multi-factorial influenced by genotype/phenotype, serum level of alpha₁-antitrypsin and compounded by smoking/ocupational exposure .^1,2