A guttural cough

A man in his 50s presented to his general practitioner with a four month history of persistent, guttural cough. The cough prevented him from completing sentences. He was a non-smoker and had no other symptoms. Chest examination by his GP was normal.

At a GP follow-up one month later the patient described increasing breathlessness and tiredness. Haemoglobin was measured at 122 g/L (normal adult male range 130-180 g/L)1 and chest radiography showed clear lungs and pleural spaces.

During this time, the patient attended a National Bowel Scope screening programme for a flexible sigmoidoscopy. This was reported as “all clear.” He had no gastrointestinal symptoms.

Two months later, the patient was still unable to speak in full sentences and requested a respiratory consultation. Chest radiography was reported as normal and a computed tomography scan was requested (see fig 1). Haemoglobin was measured at 96 g/L.1