Recurrent Hemoptysis and Renal Impairment in a 45-Year-Old Man

Salwa Ibrahim, MD

Disclosures

November 24, 2014

Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions.

Background

A 45-year-old man presents to the outpatient clinic with a 2-month history of painless bilateral ankle swelling. He also has a long-standing history of recurrent fevers that have reached 101.3° F (38.5° C) and has been suffering from a productive cough with blood-tinged sputum for more than 1 year. He has previously sought medical advice for his symptoms; at the time of his previous medical evaluation, chest radiographs and sputum analysis and culture were performed. He received empirical antituberculosis treatment for 6 months because cavitary lung lesions were seen on the chest radiographs. His sputum cultures, however, were negative, and no acid-fast bacilli were detected.

Despite treatment, his cough and fevers have persisted. The patient also complains of anorexia, an unintentional weight loss of 22 lb (10 kg) over the past year, and recurrent epistaxis. He has visited several otolaryngology clinics and was given some "nasal drops," without any improvement. No cauterization or nasal packing was ever needed. The patient had no history of easy bruising or bleeding before the episodes of epistaxis began. He recently noticed a change in the appearance of his nose and has developed a loss of smell and diminished taste. He does not smoke or drink alcohol, and he denies any illicit drug use. He denies any known exposure to tuberculosis or to experiencing any risk factors for tuberculosis exposure, such as incarceration, travel to high-risk areas, or employment in a medical facility.

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