A patient with fever, haemoptysis, and tenderness of calf muscles.

A 27-yr-old male presented to the author9s emergency room on August 22, 2000, with a 5-day history of fever, chills, and tenderness of bilateral calf muscles. He also complained of diarrhoea, cough and mild haemoptysis. The patient had a part-time job at a Chinese dessert company during summer vacations. He had been in good health previously. There was no history of blood transfusion, hepatitis, chronic liver disease, drug abuse, alcoholism or recent travel to other countries. On examination, his consciousness was clear. Body temperature was 38.8uC, blood pressure 130/90 mmHg, pulse rate 110 beats?min, and respiratory rate 22 breaths?min. The sclerae were icteric. The pupils were isocoric with prompt light reflex. The neck was supple, without jugular vein distension or lymphadenopathy. The chest expanded symmetrically and the breathing sounds were clear. There were no heart murmurs. The abdomen was soft and flat, without tenderness or rigidity. The liver and spleen were not palpable. The bowel sounds were active. Tenderness over bilateral calf muscles was noted. There were no skin rashes, petechiae, or ecchymosis. Laboratory studies revealed: a white blood cell (WBC) count of 11.1610 cells?L, with 90.5% neutrophil, 5.3% monocytes, and 3.5% lymphocytes; a red blood cell (RBC) count of 4.01610 cells?L; haemoglobin 117 g?L; and 27610 platelets?L. The prothrombin time and activated partial thromboplastin time were within normal limits. The asparate aminotransferase was 183 U?L; the creatine kinase 3,671 U?L; total bilirubin 5.8 mg?L; blood urea nitrogen 150 mg?L; and creatinine 14 mg?L. The smears of peripheral blood were negative for parasites or microfilia. The urinalysis showed microscopic haematuria (RBC 12–15 per high power field), without RBC or WBC casts. One day later, respiratory distress occurred and hypotension (68/36 mmHg) was found on August 23, 2000. The arterial blood gases showed a pH of 7.41, oxygen tension in arterial blood (Pa,O2) 5.6 kPa (42 mmHg), carbon dioxide tension in arterial blood (Pa,CO2) 3.7 kPa (28 mmHg) and HCO3 17.8 milliequivalents (mEq)?L. The patient was intubated and transferred to the intensive care unit. There was rapid progression of both hepatic and renal dysfunction. Laboratory data on August 24, 2000, revealed: total bilirubin of 153 mg?L, with a direct fraction of bilirubin of 120 mg?L; asparate aminotransferase 162 U?L; alanine aminotransferase 57 U?L; gammaglutamyl transpeptidase 86 U?L; alkaline phosphatase 141 U?L; blood urea nitrogen 91 mg?L; and creatinine 6.7 mg?L. The prothrombin time was 16 s (control, 12 s) and the activated partial thromboplastin time was 65 s (control, 37.5 s). The antibodies for human immunodeficiency virus and urine Legionella antigen were both negative. On bronchoscopy, mild bleeding was found in the bronchi over both lower lungs and the bronchoalveolar lavage (BAL) fluid was bloody. The cardiac sonography showed good contractility of the left ventricle, without organic lesions or regional wall motion abnormalities. Cultures of the blood, urine and sputum, as well as the BAL fluid, failed to yield significant growth. Imaging studies, including the initial chest radiograph on August 22, 2000 (fig. 1), the follow-up chest radiographs on the patient9s third and seventh day in the hospital (figs. 2 and 3, respectively), and highresolution computed tomographs of the chest (fig. 4), are shown.