A 71-year-old African American man presented to the emergency department (ED) with chest pain, dyspnea, and hemoptysis. He had had a few ED visits for similar symptoms within the previous 4 weeks.
The patient had hypertension and a 40-pack-year smoking history; he currently smoked. There was no family history of malignancy.
Temperature was 36.8°C (98.3°F); heart rate, 86 beats per minute; respiration rate, 24 breaths per minute; and blood pressure, 120/70 mm Hg. Oxygen saturation was 98% on 2 liters of oxygen. Oral thrush was evident. There was no palpable lymphadenopathy. Heart rhythm was irregular with a loud P2; there were no appreciable murmurs. Chest examination showed diffuse bilateral wheezes and dullness to percussion at both lung bases. There was no palpable hepatomegaly or splenomegaly. No pedal edema was noted. Results of a neurological examination were nonfocal.
White blood cell count was 3200/μL; hemoglobin level, 15.9 g/dL; and platelet count, 54,000/μL. The absolute neutrophil count was 900/μL. A chemistry panel revealed the following levels: sodium, 136 mEq/L; potassium, 3.4 mEq/L; chloride, 91 mEq/L; creatinine, 1.04 mg/dL; and calcium, 9.5 mg/dL. His coagulation profile showed a partial thromboplastin time of 28 seconds and an international normalized ratio of 1.0.
A CT scan of the chest showed an amorphous soft tissue mass that encased and constricted the right main pulmonary artery and the right main stem bronchus (A). Extensive round masses were visible in the liver; the largest mass was in the right medial hepatic lobe and measured 2.7 × 2.4 cm (B).
An extensive evaluation of the patient's mass lesions and cytopenias was initiated. He was HIV-positive, but results of tests for hepatitis B and C were negative. Liver function tests revealed the following levels: albumin, 3.1 g/dL; total protein, 5.8 g/dL; direct bilirubin, 0.3 mg/dL; total bilirubin, 1.0 mg/dL; alkaline phosphatase, 175 U/L; alanine aminotransferase, 156 U/L; and aspartate aminotransferase, 92 U/L. Haptoglobin level was 27 mg/dL, and lactate dehydrogenase level was elevated at 1168 U/L. The fibrinogen level was normal at 274 mg/dL, but the D-dimer level was elevated at 602 ng/mL. Results of an enzyme-linked immunosorbent assay for heparin(Drug information on heparin)-induced platelet antibodies were negative. A review of the peripheral smear (C) showed no platelet clumping, schistocytes, or immature cells. Blood and urine cultures showed no bacterial or fungal growth.
