Case 1: Hemoptysis in a Healthy 13-year-old Boy

Presentation

A previously healthy 13-year-old boy presents with cough and hemoptysis of 1 week duration. His cough is nonproductive and he describes a small amount of hemoptysis every day. There is no history of fever, changes in appetite, weight loss, exercise intolerance, orthopnea, or chest pain. His mother does report that he has had occasional night sweats.

Vital signs at the time of hospital admission are as follows: temperature, 100.8°F (38.2°C); heart rate, 100 beats/min; blood pressure, 109/55 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 98% on room air. His weight is 76 lb (34.4 kg) (<1st percentile). Physical examination findings are normal.

Laboratory studies include the following: white blood cell count, 7,400/μL (7.40×10⁹/L); hemoglobin level, 7.9 g/dL (79 g/L); red blood cell count, 7.04×10³/μL; mean corpuscular volume, 79.7 μm³ (79.7 fL); reticulocyte count, 1.7% (0.017); platelet count, 420×10³/μL (420×10⁹/L); and elevated inflammatory markers, with an erythrocyte sedimentation rate of 92 mm/hour and a C-reactive protein level of 4.9 mg/dL (49 mgL). His serum electrolyte levels and liver function test results are normal.

His initial chest radiograph shows consolidation in the right upper lobe. Due to concern for tuberculosis (TB), quadruple anti-TB medications (rifampim, ethambutol, isoniazid, and pyrazinamide) are started on admission. Additional evaluation includes QuantiFERON-TB Gold (Qiagen, Hilden, Germany), sputum acid-fast bacillus stain and culture, aerobic respiratory culture, human immunodeficiency virus antibody screen, and histoplasma antibody and mycoplasma immunoglobulin (Ig) M and …