A 14-yr-old male with dyspnoea, productive cough and chest pain.

A 14-yr-old White male was referred to the Urology Unit of the G. Gaslini Institute because of a post-traumatic urethral stenosis (arising from a bicycle accident) that, during the previous 18 months, had required repeated endoscopic urethral dilation manoeuvres at the patient9s local hospital. Apart from the urethral stenosis, the patient had been in excellent health until 2 months before admission, when slowly progressive exertional dyspnoea, associated with nonproductive cough and right-sided posterior chest pain, developed. On admission, the patient appeared in good clinical condition. Decreased percussion and auscultatory sounds were noted over the middle and lower portions of the right hemithorax. A summary of the results of the blood tests performed on admission is shown in table 1. Chest radiography (fig. 1) and high-resolution computed tomography (HRCT) (fig. 2) were performed. Thoracocentesis was performed and 500 mL haemorrhagic pleural fluid aspirated. Pleural fluid analysis did not show any cytological changes suggesting malignancies, amylase levels were within the normal range and microbiological evaluation results were negative for bacteria, fungi, mycoplasmata, mycobacteria and viruses. Plasma D-dimer levels were slightly elevated but ultrasonography of the deep venous system did not show signs of thrombosis in the legs, penis or pelvis. Echocardiographic evaluation did not demonstrate any right ventricular dysfunction. Ultrasonographic examinations showed that there were no abnormalities of the abdominal organs and no peritoneal effusion and ruled out the presence of testicular or thyroid tumours. Fibreoptic bronchoscopy was then performed and did not reveal any airway abnormalities. Bronchoalveolar lavage analysis was nondiagnostic (no siderocytes suggestive of pulmonary haemorrhage, acid-fast bacilli, bacteria, viruses, fungi or malignant cells were identified in the epithelial lining fluid or lavage fluid cells). Thoracoscopy to obtain lung tissue biopsy specimens and pleurodesis were then performed and the removed specimens sent to a pathologist for morphological evaluation of pleural (fig. 3) and lung tissues (fig. 4).