A 29-yr-old African male was admitted with a 1-week history of chest pain, shortness of breath and haemoptysis. He had returned from Africa by plane 2 weeks previously. The patient denied fever, sweats or weight loss. He had no significant past medical history, was not taking any regular medication, and was a lifelong nonsmoker. He lived in the UK and was in full-time education.
Physical examination did not reveal any abnormalities. Laboratory investigations showed elevated inflammatory markers, including an erythrocyte sedimentation rate level of 59 mm·h−1 and a C-reactive protein level of 53 mg·L−1, normal haemoglobin at 139 g·L−1 and leukocytosis of 14.6×109·L−1 with a predominance of neutrophils. Chest radiograph was normal. Computed tomography (CT) pulmonary angiography confirmed the presence of filling defects within branches of the right lower lobe, left lingular and left lower lobe pulmonary arteries, with no radiological evidence of right heart strain. Small nodules of ≤7 mm were identified in both lungs (fig. 1⇓). Several small mediastinal nodes were also identified. The patient was anti-coagulated with warfarin for bilateral pulmonary thromboembolism.
The patient had further episodes of atypical chest pain and haemoptysis over the following month. He was readmitted with signs of right heart failure and normocytic …