A patient with haemoptysis, rapidly changing pulmonary infiltrates and left flank pain

Abstract

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

Pancreatic Tail Cancer with Sole Manifestation of Left Flank Pain: A Very Rare Presentation

“…These causes other than renal calculi include abnormalities of the gastrointestinal and gynecologic systems, as well as other abnormalities of the genitourinary system. Some very rare etiologies, such as acute pancreatitis [6], pulmonary thromboembolism [7], spleen or renal infarction [8], and carcinomas, have been reported. In our patient, the only symptom was persistent dull left flank pain, which led to a wide range of misdiagnoses, even though she was seen by many specialists who also performed several different investigations.…”

The lung physician and the antiphospholipid syndrome

“…Alveolar haemorrhage, apart from that associated with ARDS, can also occur in a less dramatic setting, where the patient presents with dyspnoea and large alveolar infiltrates seen on chest roentgenogram [5,6]. Even substantial alveolar haemorrhage rarely causes large haemoptysis; indeed, the patient usually reports only small amounts of blood in the sputum, despite the fact that the haemoglobin level has decreased considerably and the chest roentgenogram shows large infiltrates [3,[4][5][6][7]. Typically, the lung has the capacity to clear the alveoli of blood within a few days, with subsequent improvement of the radiograph and the dyspnoea.…”