A patient with haemoptysis and a smaller right lung.

A 41-year-old businessman was admitted to National Taiwan University Hospital for evaluation of a 2-week history of haemoptysis productive of 50–100 mL of fresh blood daily. The patient stated that haemoptysis had first occurred 10 yrs earlier, had lasted for about 1 month and had spontaneously subsided. Both episodes of haemoptysis were preceded by flu-like symptoms. There was no past history of epistaxis, exertional dyspnoea, or loss of body weight. Physical examination revealed a well-developed man in no distress. His blood pressure was 112/70 mmHg, pulse 96 beats.min-l and respiratory rate 22 breaths.min-1. There was a slightly decreased chest wall excursion, and breath sounds in the right hemithorax. No audible bruits were heard over the chest. Heart sounds were regular, without murmurs. No clubbing, cyanosis, telangiectasia or oedema were noted. Arterial blood gases in room air showed: a pH of 7.41; arterial carbon dioxide tension (Pa,CO2) of 4.9 kPa (36.5 mmHg); and arterial oxygen tension (Pa,O2) of 13.1 kPa (98.3 mmHg). The sputum was negative for acid-fast bacilli, fungi and malignant cells. An electrocardiogram was normal. Echocardiography showed normal cardiac size and good left ventricular contractility, with no evidence of congenital cardiac lesions or pulmonary hypertension. On bronchoscopy, no endobronchial lesion or definite site of bleeding was found. Imaging studies, including a posteroanterior (PA) chest radiograph (fig. l), and computed tomography (CT) scan at the level of the aorticopulmonary window (fig. 2) are shown. CASE FOR DIAGNOSIS