A A p pa at ti ie en nt t w wi it th h h ha ae em mo op pt ty ys si is s, , r ra ap pi id dl ly y c ch ha an ng gi in ng g p pu ul lm mo on na ar ry y i in nf fi il lt tr ra at te es s a an nd d l le ef ft t f fl la an nk k p pa ai in n Case history A 28 year old male patient sought medical advice because of a 2 week history of haemoptysis. He began to suffer from vague right chest pain 1 month earlier, followed by intermittent fever, progressive dyspnoea and cough with blood clots in the sputum. Occasional left upper quadrant and left flank pain were also noted. He lost 6 kg in weight during this period. Pneumonia was suspected from the initial chest radiograph ( fig. 1a) at a local hospital, and antibiotics were prescribed for 5 days but without significant benefit. The patient was referred to this hospital for a second opinion.The past medical history was noncontributory. Physical examination revealed a well-developed man in mild respiratory distress. The body temperature was 37°C, blood pressure was 130/70 mmHg, pulse 100 beats·min -1 , and respiratory rate 30 breaths·min -1 . Breathing sounds were diminished in bilateral lower lung fields, with some crackles. Heart sounds were regular and without murmurs. There was tenderness of the left costovertebral angle and mild swelling of the right thigh. No skin rash was detected, with the exception of some ecchymosis at the right inguinal area. Neither digital clubbing nor splinter haemorrhage was found. A complete blood count revealed: white blood cells (WBC) 24.4×10 9 cells·L -1 ; haemoglobin (Hb) 110 g·L -1 ; and 86×10 9 platelets·L -1 . Determination of arterial blood gas values in room air showed: a pH of 7.48; arterial carbon dioxide tension (Pa,CO 2 ) of 4.8 kPa (36 mmHg); and arterial oxygen tension (Pa,O 2 ) of 9.4 kPa (71 mmHg). Prothrombin time and partial prothrombin time were both prolonged. Sputum was negative for acid-fast bacilli (AFB), fungi and malignant cells. Urinalysis was normal.Imaging studies, including a follow-up chest radiograph 5 days later ( fig. 1b), the sequential contrastenhanced computed tomographic (CT) scans at the level of the aorticopulmonary window ( fig. 2a), of the lower thorax ( fig. 2b), and of both kidneys ( fig. 3), are shown. CASE FOR DIAGNOSIS

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