Introduction

A 19-year-old male patient with a history of asthma was in good health until he developed a sudden-onset, right side pleuritic chest discomfort and shortness of breath. At that time, he was on a cruise to Puerto Rico. He returned home 1 week later and was evaluated in the emergency room at that time. On further history, he denied cough, fever, chills, night sweats, weight loss, sputum production, haemoptysis or other symptoms. He did not recall recent sick contacts or exposure to tuberculosis. He was born in the USA and this cruise was his only recent travel. He worked in a law firm and denied significant occupational exposures, any tobacco or drug use, allergies or significant family history of lung or cardiovascular disease. Tachycardia was the only abnormality on his physical examination, and initial laboratory testing were completely normal. His pulse oximetry measurement was 97% O₂ saturation on room air at rest. His ECG was consistent with sinus tachycardia, with a rate of 108/min and no ST–T wave changes. He was admitted to the hospital for further investigation of his chest pain.

His chest radiograph (figure 1A) and chest CT scan (angiogram protocol) (figure 1B) were abnormal but showed no evidence of pneumothorax or pulmonary embolism. A small unilateral pleural effusion was present but was too small to sample using bedside ultrasonography. All subsequent blood tests in the hospital including cardiac enzymes, immunoglobulins levels and vasculitis screen were all unremarkable. The chest …