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What Caused Cough and Hemoptysis in a Patient Recently Treated for Exudative Tonsillitis?

What Caused Cough and Hemoptysis in a Patient Recently Treated for Exudative Tonsillitis?

A 22-year-old man presented
with a 3-week history of
cough and hemoptysis with
right-sided chest pain and decreased
oral intake associated with a 4.5-kg
(10-lb) weight loss. Ten days before
hospital admission, he was involved
in a fistfight, which resulted in his arrest.
He was taken to jail and placed
in a holding cell for 3 hours. Shortly
before his pulmonary symptoms developed,
he was seen by his primary
care physician because he had a sore
throat and exudative tonsillitis, for
which amoxicillin/clavulanate was
prescribed. He stopped taking the
antibiotic after 3 days.

The patient's medical history was
significant for childhood asthma and
whooping cough. He underwent an
adenoidectomy at age 5 years and
an inguinal hernia repair at age 11
months. He works as a mechanic
and lives with his mother. Each day,
he smokes half a pack of cigarettes
and drinks two 24-oz bottles of beer.

In the review of systems, it was
discovered that in the 3 weeks preceding
this visit, the patient had fairly
severe myalgia, weakness, and fatigue.
He takes no medications and
has no known drug allergies. There
is no history of sick contacts, tuberculosis
exposure, or recent travel,
and there are no pets in the patient's
household.

On presentation, his temperature
was 39.1C (102.4F), his pulse rate
was 100 beats per minute, his respiration
rate was 22 breaths per
minute, and his blood pressure was
120/70 mm Hg. His weight was 58.5
kg (129 lb). He had good dentition
and oral hygiene. His posterior
oropharynx was markedly erythematous,
and no exudate was noted.
Wheezing was heard in the right
upper lung field. All other findings
from the physical examination were
normal.

Initial laboratory studies yielded
the following results: white blood
cell (WBC) count, 9730/mu;L, with
65% segmented neutrophils, 13%
lymphocytes, 8% monocytes, and
4% eosinophils (this WBC count was
decreased from 14,000/mu;L, which
was recorded 21 days earlier); hemoglobin
level, 11.7 g/dL; hematocrit
value, 36.3%; platelet count,242,000/mu;L; C-reactive protein level,
15.1 mg/L; and erythrocyte sedimentation
rate, 86 mm/h. Findings
from a complete metabolic panel
were essentially within normal limits.
Aurinalysis revealed trace leukocytes,
protein, and blood. A urine
drug screen was positive for opiates
and cocaine.

Findings from both a chest radiograph
and a CT scan of the chest indicated
a thick-walled cavitary lesion
in the right chest.

DIFFERENTIAL DIAGNOSIS

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