A 35-Year-Old Man with Dyspnea and Hemoptysis

WHAT IS YOUR DIAGNOSIS? A man in his thirties was admitted due to new onset dyspnea, right-sided pleuritic chest pain and non-massive hemoptysis since 4 days before admission. On arrival, he was febrile and tachypneic with normal blood pressure. Bibasilar decreased breath sounds and vocal vibration, prominently in the right lung, and 2cm difference in diameter of the left leg were the remarkable findings. Blunting of the right costophrenic angle was prominent on chest x-ray. Laboratory analysis revealed normal blood cell count, elevated erythrocyte sedimentation rate (125 mm/hr.) and positive quantitative D-Dimer. Blood biochemistry and coagulation profile and urinalysis were normal. Anticoagulant was initiated with presumptive diagnosis of pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT). Doppler ultrasonography (DUS) and pulmonary computed tomographic angiography (CTA) were performed. DUS was normal, but right sided pulmonary artery embolus was confirmed with CTA (Figures 1 and 2). Interestingly, DUS revealed DVT in the right popliteal artery. Echocardiography was normal. Despite anticoagulative therapy, dyspnea progressed and the patient’s general condition deteriorated. Pleural fluid analysis showed lymphocyte dominant exudate.