Not Your Typical Hemorrhagic Pleural Effusion

A 36-year-old white man with a 20 pack-year smoking history, childhood asthma, and previous heavy alcohol use presented with progressive dyspnea on exertion and chest tightness for the past month. He lived in the Los Angeles area, but frequently hiked in the Southern California area, including twice in the past year around Bakersfield, and after one trip about 9 months prior, noted a febrile illness that he felt may have been related to an insect bite. He was seen in our Emergency Department with a low-grade fever (T = 38.06°C [100.5°F], tachycardia to 142 beats per minute) and sharp right-sided head pain. A chest film and laboratories were unremarkable, and his symptoms resolved with a combination of ketorolac, acetaminophen, and intravenous fluids. He was discharged with analgesics and, while he had resolution of his fever and chills, he noted some persistent chest discomfort. About 4 months prior to admission, he was incarcerated for about 5 days following a verbal altercation, but he specifically denied any physical injury associated with the encounter. He also stopped smoking around that time, and in the ensuing weeks noted slowly progressive chest tightness, malaise, and a non-productive cough. He had been treated by his primary care physician with 2 outpatient courses of oral antibiotics without relief. He sought medical attention again in the Emergency Department and endorsed dyspnea at rest and exertion, anorexia, and 10 pounds of weight loss.