A man in his 30s with recurrent cough, fever, dyspnoea, and chest pain

A man in his 30s was admitted to the respiratory and critical care ward with a >2 month history of recurrent cough, fever, dyspnoea on exertion, and pleuritic pain in the left hemithorax but no haemoptysis.

Two months earlier, chest radiography had shown pulmonary infiltrates, and antibiotic treatment was unsuccessful. One month earlier, pulmonary embolism (PE) was diagnosed after blood gas analysis showed hypoxaemia, and chest computed tomography pulmonary angiography (CTPA) showed multiple filling defects affecting the main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA). At that time, the patient’s laboratory results, compression ultrasonography (CUS), and echocardiography were normal, and he was treated with rivaroxaban and discharged.

At this latest presentation, his heart rate was 78 beats/min, temperature 36.7°C, respiration rate 21 breaths/min, blood pressure 119/76 mm Hg, and oxygen saturation was 97% on room air. Chest, abdominal, and lower limb examination was normal. Routine blood tests, blood gas analysis, testing for troponin I, B-type natriuretic peptide, and prothrombin time, and thrombophilia screening were …