A 22-year-old male was admitted to Valiasr Hospital affiliated to Birjand University of Medical Sciences Iran, with complaints of painful swelling of the left lower limb for the last two days. His vital signs were stable (oral temperature 37.3oC, pulse rate = 67, respiratory rate = 16, systolic blood pressure = 120 and diastolic blood pressure = 80) and his physical examinations, except, the swallowed tender left leg (from ankle up to the thigh) were unremarkable. Chest-x-ray, abdominal sonography and echocardiography were normal. CBC revealed mild normocytic anemia (Hb: 11 gr/dl) with normal WBC and Plt count (6.4, 172*103 respectively). The erythrocyte sedimentation rate and the c reactive protein were elevated unexpectedly (ESR = 50 mm/h, CRP = >10mg/L). Routine biochemical investigations, thyroid function tests and tumor markers were normal. He had neither undergone any major surgeries in recent past nor history of prolonged immobilization, other diseases and smoking. Ultrasound Doppler study of the left lower limb revealed DVT in left popliteal up to external iliac veins. The patient was treated through catheter directed thrombolysis (CDT) with infusion of streptokinase 250.000 unit stat and 100.000 unit per hour infusion for 48 hours with concomitant 500 unit per hour of heparin and taking warfarin tablets 5mg/daily. During hospitalization he had severe pleuritic chest pain that we thought that is due to small distal pulmonary embolism which is a common finding in venous thromboembolism. The patient discharged from hospital with a good general condition after 10 days with international normalized ratios (INR = 2), partial thromboplastin time (PTT = 30) and Prothrombin Time (PT = 18.4). A high sedimentation rate (ESR: 50) was our question mark at the patient discharge time when all primary evaluations were normal. The day after discharge, the patient re-admitted with cough, haemoptysis and pleuritic chest pain. The patient had blood -streaked sputum 6 times a day which was not massive (10 cc/24h). Laboratory tests showed an elevated ESR (80 mm/h) and CRP (139 mg/l). There was hemoglobin decline (hgb = 10.5 gr/dl). Biochemical findings were within normal limits. CXR and pulmonary CT angiography showed minimal pleural effusion and massive PTE and pulmonary necrosis were ruled out (Figure 1, Figure 2). Along with His subjective and objective findings a clinical suspicion to TB was raised that a surprising positive result of the sputum for acid fast bacilli (3 samples) confirmed it. Since the patient's symptoms were in the context of pulmonary tuberculosis, not lung infarction, he was referred to infectious service for TB treatment.
The patient's CT pulmonary angiography.