A Twenty-Year-Old Woman with Hemoptysis

WHAT IS YOUR DIAGNOSIS? A twenty-year-old woman was admitted due to non-massive hemoptysis and low grade fever from a few days earlier. She reported productive cough, no chills, no chest pain and no shortness of breath. On admission, she was stable with mild fever and no respiratory distress or tachypnea; the remainder of physical examinations was normal. She mentioned a history of diabetes mellitus type one (DM1) since a few years ago. Surprisingly, she was on oral agents for DM1. She was well until approximately a month ago when she developed episodes of unconsciousness and she was admitted to a hospital with diabetic ketoacidosis. After intensive care, the patient was discharged in an improved condition. She was a single employee, with no travel history in recent months. She was neither a drinker nor a smoker and was not using any illicit drugs. Allergic history was unremarkable. Laboratory analysis showed normal complete blood cell and differential counts, electrolyte levels and renal and liver function tests with 250 mg/dl random glucose level. Analysis of arterial blood gases revealed no acidosis and urinalysis showed no ketonuria. Initial chest x-ray and chest computed tomography (CT) scan are shown in Figure 1. Chest CT-scan revealed bilateral alveolar infiltration which was greater in the left lung with a central parahilar cavity in the right side in addition to right hilar and subcarinal adenopathy. Mild pleural effusion in left side was seen. On high resolution chest CT-scan, bilateral patchy ground glass opacity involving upper lobes, right middle lobe and superior segment of lower lobes was detected (Figure 1). Based on imaging findings, after repeated negative acid fast staining of sputum smears, bronchoscopy was performed. An intrabronchial tumor with full obstruction of right main bronchus associated with diffuse necrosis of the bronchi and severe secretion was reported. The necrotic mass was partially removed with rigid bronchoscopy.