A 37-year-old male was referred to the Emergency Department by his general practitioner because of progressive dyspnoea. Medical history was uneventful. He smoked at least 10 cigarettes a day (no e-cigarettes) and did not use drugs. He had not been abroad, had no exposure to animals or chemicals, and delivered papers for a living. A week before presentation, he visited a steam bath in a sauna facility, felt a crack in his upper body and was progressively dyspnoeic since. He only coughed occasionally and did not have a fever, although he experienced heavy perspiration over the last couples of days. Physical examination showed a sweating and dyspnoeic patient, with a respiration rate 28/minute, SatO2 94% without supplementary oxygen, heart rate 140/minute, blood pressure 200/140 mmHg and a temperature of 36.7 °C. On auscultation of the lungs, we noticed mild crackles and some inspiratory squawks. Examination of abdomen and extremities was normal. Laboratory results showed an erythrocyte sedimentation rate 100 mm/hour, haemoglobin concentration 8.0 mmol/l, leucocyte count 17.3 x 109/l, platelet count 479 x 109/l, C-reactive protein 257 mg/l, normal kidney function, normal bilirubin, alkaline phosphatase 155 U/l, gamma glutamyl transferase 168 U/l, aspertate aminotranferase 43 U/l, alanine aminotransferase 16 U/l, and lactodehydrogenase 2523 U/l. The patient refused an arterial puncture for arterial blood gas analysis. EKG showed a sinus tachycardia, without abnormalities. The chest X-ray (figure 1) surprised and alarmed us.
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