45-Year-Old Male With Dyspnea, Chronic Chough, Significant Weight Loss, and Episodes of Massive Hemoptysis

Question: A 45-year-old man with a history of illicit drug dependence on heroin and opiate presented with complaints of progressive shortness of breath and chronic productive cough for the previous 3 months. The patient had recent development of 4 episodes of massive hemoptysis in the previous week. Upon the initial emergency consultancy, the patient was hemodynamically unstable with signs of function class-IV dyspnea, oxygenic saturation = 80%, tachypnea (respiratory rate = 22/minute), tachycardia (pulse rate = 130/minute), Fever (axillary temperature = 31.8°C), and hypotension (BP = 95/60 mmHg). On clinical examination, reduced respiratory sounds predominant on the right side, significant weight loss, and 2 plus pitting edema was obtained. In the primary routine hematologic examination, uncompensated respiratory acidosis consistent with microcytic anemia, direct hyperbilirubinemia, elevated inflammatory markers (ESR and qualitative C-reactive protein [CRP]), and thrombocytopenia was revealed. The lung computed tomography (CT) (Figure 1) showed the following characteristics: (1) multiple nodularity in variable sizes randomly distributed in both lungs along with the evidence of 4 thick-wall cavitary lesions, (2) diffuse centrilobular micro-nodules with tree in the bud pattern, (3) hydropneumothorax in the left lung, and (4) a hyper-dense structure measuring at 72 millimeters in diameter, within left upper lobe with a marginal lucence crescent. The patient underwent contrast-enhanced computed tomographic pulmonary angiography (CTPA) due to the appearance of a structure in the lung CT scan suspected to be of vascular origin which is shown in Figure 2.