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A 25-year-old patient with spontaneous hemothorax.

A 25-year-old African-American woman with a chief complaint of progressive dyspnea and cough presented to the inpatient service after her primary care physician noted a significant right-sided pleural effusion on a chest radiograph. She had a 2to 3-year history of intermittent, sharp, pleuritic chest pain radiating from the right subscapular region, across the anterior chest, and down the right arm that worsened with cough and accompanied this episode. Three months prior to hospital admission, dyspnea had developed with exertion and cough productive of white sputum. She sought medical attention 2 months prior to hospital admission, but two courses of outpatient antibiotic therapy did not ameliorate her condition. Her activity level deteriorated from unrestricted walking to dyspnea at rest. She was receiving no medications, and did not drink alcohol, smoke cigarettes, or use recreational drugs. Coccidioidomycosis was previously diagnosed in a family member. The patient had noted occasional abdominal bloating, night sweats, and chills without fever, and an 8-lb unintentional weight loss over the previous 3 months. She had no known tuberculosis exposures, and a recent tuberculin skin test result was negative. She denied rash, joint pain, nausea, hemoptysis, orthopnea, hematochezia, dizziness, visual changes, dyspareunia, or dyschezia. She has a history of dysmenorrhea and was on her menses at the time of hospital admission. In the emergency department, she was noted to have a large, right-sided pleural effusion (Fig 1). Thoracentesis revealed bloody fluid. A chest tube was inserted and drained 2.6 L of bloody pleural fluid. On examination, the patient was a thin, AfricanAmerican woman in no distress. Her chest examination revealed an appropriately placed chest tube, a soft-tissue fullness over her right scapula, which was tender to palpation, and absent breath sounds on the right side. Ascites, without organomegaly, was present on abdominal examination. The remainder of the examination was normal.