Pulmonary hematoma presenting as pseudotumor

A 65-year old man presented at the emergency department with acute shortness of breath, chest pain, cough and haemoptysis. The patient is an ex-smoker with a total of 35 pack years and an extensive medical history, including a serious traffic accident with neurotrauma, chronic obstructive pulmonary disease, degenerative spine and hip disease, ethylism, a type A aortic dissection and atrial fibrillation. His medication list is extensive and includes a bronchodilator, an antiepileptic, several antihypertensive drugs, pain medication, amiodarone, acetylsalicyc acid and subcutaneous low molecular weight heparin. Chest X-ray showed a rounded opacity in the mediobasal segment of the right lower lobe that could not be seen on previous radiographs (Fig. A). Biochemistry demonstrated an elevated CRP (48 mg/L) and elevated D-dimers (2190 ng/ml). CT thorax was performed to rule out pulmonary embolism. CT thorax showed a sharply demarcated relatively hyperdense mass (mean density on pulmonary artery phase images of 46 HU) with a maximum diameter of 5,5 cm in the mediobasal segment of the right lower lobe abutting the distal vena cava superior (Fig. B). An endobronchial ultrasounded (EBUS) guided biopsy of the lesion was performed. Pathologic examination showed pulmonary tissue with signs of hemorhage and fibrotic changes. No signs of malignancy were seen. An old thorax CT made in another hospital revealed that the location of the mass corresponded exactly with the location of a large bulla (Fig. C). Based on this new information the diagnosis of pulmonary hematoma within a bulla was made.