A 40-Year-Old Man with Massive Hemoptysis

A 40 year-old taxi driver residing in Tehran presented with two episodes of massive hemoptysis following a 3-week period of productive cough, dyspnea on exertion, fever, night sweat, anorexia and weakness. He was a heavy smoker (40 packs per year), and an IV drug user since 5 years ago with a history of imprisonment 3 years ago. He had no history of alcohol consumption or unprotected sexual contact. His physical examination revealed poor oral hygiene, diffuse coarse crackles in lungs, edema of the lower extremities which was dominant in the left leg and no petechia, purpura or any other skin lesion. He had normal blood biochemistry, liver function tests and electrolytes. Complete blood count revealed a microcytic, hypochromic anemia with a PMN dominant leukocytosis and normal platelet count. Erythrocyte sedimentation rate was 87. PPD was non-reactive and 3 times sputum smear for acid fast bacilli was negative. Urinalysis was normal. Chest x-ray (Figure 1) and lung CT-scan (Figure 2) were performed. Transthoracic and transesophageal echocardiographies (TTE & TEE) were reported to be normal without vegetation or other abnormalities.