A 38‐year‐old otherwise healthy Laotian refugee presented with a week of fevers, cough, and hemoptysis. He had initially been treated for pneumonia but soon developed progressive headache, somnolence, and myoclonic jerks. Basic labs were normal except for an eosinophil count of 600,000/mm3. A noncontrast brain computed tomography (CT) demonstrated periventricular hemorrhage and hydrocephalus requiring emergent ventriculostomy, with unrevealing cerebrospinal fluid (CSF) analysis. Magnetic resonance imaging (MRI) of the brain showed an enhancing choroid plexus lesion. CT of the chest revealed mild hilar lymphadenopathy and a 9‐cm calcified pleural lesion, which on biopsy was nongranulomatous, necrotic tissue. A positive serum interferon gamma release assay and tuberculosis skin test led to discharge with empiric treatment for tuberculosis (TB) with pending mycobacterial cultures. A month later he was readmitted for a seizure and progressive hemoptysis, and repeat MRI showed a new 7‐mm hemorrhage in the hippocampal commissure. Earlier cultures for mycobacteria along with an extensive serologic workup of fungal, parasitic, and viral infections were negative, and brain biopsy was deferred out of concern for iatrogenic hemorrhage. In pursuit of his hilar lymphadenopathy, bronchoscopy revealed an unexpected endobronchial lesion that, on biopsy, was a poorly differentiated epithelioid angiosarcoma. Days later, the patient suffered from seizures due to progressive intracranial hemorrhage with midline shift, and comfort measures were pursued per the patient and family's wishes.
With an emphasis on reducing length of hospital stay, hospitalists are often confronted with the decision to discharge patients without definitive diagnoses while awaiting tests results. In this case, the simultaneous findings of a likely history of infection with TB and a “neuropulmonary” syndrome led to a presumptive discharge diagnosis of disseminated tuberculosis. The differential diagnosis included other bacterial, fungal, or parasitic infections (e.g., nocardiosis, coccidioidomycosis, paragonimiasis), sarcoidosis, vasculitis, and neoplasia. When serologic testing and cultures failed to make a diagnosis, a small, friable endobronchial mass led to the diagnosis of epithelioid angiosarcoma — a rare, rapidly progressive vascular tumor with very high mortality. In retrospect, the scant hemoptysis on presentation, although initially overshadowed by devastating central nervous system findings, ultimately provided a critical diagnostic clue to a disseminated, life‐threatening vascular process.
Hospitalists must frequently balance the risks and costs of hospitalization against the value of lengthy and invasive inpatient diagnostic endeavors. With a rapidly progressive presentation of a disease with seemingly disparate signs and symptoms, early tissue sampling may be required.