(CHEST 2005; 128:1022–1027) A 77-year-old man presented for evaluation of hemoptysis after a 7-month history of cough, progressive dyspnea, and intermittent hemoptysis, which consisted of tablespoon amounts of bright red blood and occurred up to eight times per day. Episodes of intermittent blood-streaked sputum had occurred for 18 months. He denied fevers, rigors, chest pain, palpitations, headaches, nasal symptoms, gastroesophageal reflux, melena, hematochezia, or hematuria. There were no known liver, kidney, or hematologic disorders. The physical examination findings were normal, except for a 4/6 apical pansystolic murmur. Three years earlier, the patient had experienced an episode of out-of-hospital cardiac arrest that had been attributed to a subendocardial myocardial infarction, from which he was successfully resuscitated. Subsequently, cardiac catheterization revealed severe three-vessel coronary occlusion. Coronary artery bypass surgery was performed without any complications. At the time of catheterization, he had normal ventricular size and function, and no evidence of valvular abnormalities. Other medical comorbidities were arterial hypertension and peptic ulcer disease. The patient had smoked for approximately 20 years (1 pack of cigarettes per day on average) and had quit 22 years before diagnosis of the acute coronary syndrome. No other occupational or environmental noxious exposures were identified. He denied any history of HIV exposure, and the results of a recent enzyme-linked immunosorbent assay had been negative. His family history was consistent only for myocardial infarction (both parents, at a young age). A chest radiograph showed persistent left lower lobe infiltrates (for approximately 4 months), and the results of blood tests consisted of a normal CBC count, normal metabolic panel, normal urinary sediment level, and normal coagulation studies (ie, prothrombin time and activated thromboplastin time). Tests for the presence of antineutrophil cytoplasmic antiglomerular basement membrane, antiphospholipid, and antinuclear antibodies were all negative. A previous bronchoscopy, which had been performed to evaluate the patient’s hemoptysis 3 months before the current presentation, showed no endobronchial source of bleeding and no intraluminal abnormalities. A repeat echocardiogram showed normal left ventricular contractility, severe mitral regurgitation, with mild mitral annulus calcification, and a mildly dilated left atrium. No vegetation was seen on a transesophageal echocardiogram. The chest radiograph and CT scan at presentation are shown in Figures 1 and 2, respectively. A diagnostic procedure was performed.