A 15-year-old girl presented to her local hospital with a 4-month history of fatigue, anorexia, and a 6-kg weight loss. She also reported fever, productive cough, and chest pain on the left lower chest posteriorly for 4 days before admission. Her medical history and systemic review were unremarkable for any respiratory or other organ disease. The patient was taking iron and multivitamin supplements. At her local hospital, she was febrile; chest radiography showed anemia and a left lower lobe infiltrate. She received a transfusion and was started on empiric antibiotics that were continued for 10 days without improvement. Subsequently, CT scan of the chest and upper abdomen showed a lung abscess and left renal mass that led to a referral to our center.

A 63-year-old woman without significant medical history presented to an urgent care center with a 3-day history of fatigue and dyspnea on exertion. She was found to have an oxygen saturation in the low 80s on room air and was transferred to the closest hospital for further evaluation. Initial chest radiographs showed extensive bilateral interstitial opacities favoring the mid to lower lungs. A general infectious workup was unrevealing. The cause of her symptoms was thought to be an atypical bacterial or viral infection. She was discharged home on supplemental oxygen, 2 L/min via nasal cannula; instructed to finish a 7-day course of antibiotics; and given strict return precautions. Six days later she returned to the ED with worsening dyspnea despite finishing the prescribed course of antibiotics; she was admitted for further evaluation. She had emigrated from Northern India in the early 2000s. While in India, cooking was performed over an open fire. Their home was situated on a poultry farm. She has never smoked. She was up to date on typical cancer screening. She had no pets and denied further exposure to birds since moving to the United States. Her occupational history included manufacturing, but she denied significant exposure to dusts or metal shavings.

A 78-year-old man with a history of GI stromal tumor (GIST) in the stomach with metastasis to the liver presented with progressive shortness of breath, dry cough, and subjective fever that started 1 week after radioembolization of liver metastatic lesions. His initial diagnosis of GIST was 10 years before, for which he underwent surgical resection; however, more recently he was noted to have hepatic lesions biopsy-proven to be metastatic GIST lesions. He stated that he did not have any respiratory symptoms before the radioembolization procedure and denied having a history of pulmonary disease. His medical history was otherwise notable for coronary artery disease post coronary artery bypass graft in 2002, heart failure with reduced ejection fraction, and atrioventricular block after pacemaker placement. After the diagnosis of liver metastasis, he began treatment with imatinib 6 months earlier and consequently received radioembolization with yttrium-90 (Y-90) microspheres.

A 71-year-old man with a history of recurrent tonsillar squamous cell carcinoma was admitted to the hospital with oropharyngeal bleeding. He received high-dose radiation therapy with curative intent. On day 4 of hospitalization, he demonstrated hypoxia resulting from an airway mucus plug and was brought to the medical ICU.

Tranexamic acid is a commonly used hemostatic agent with broad clinical uses across multiple specialties. Systemic toxicity is due to gamma-aminobutyric acid type A and glycine receptor competitive antagonism and has been reported by multiple routes, but toxicity after pulmonary administration via nebulization and BAL has not yet been described. A 44-year-old man with a history of congenital pulmonary arteriovenous malformations underwent routine bronchoscopy for hemoptysis. He received preprocedure nebulized tranexamic acid 500 mg three times daily for 48 h. An additional 1,000 mg was given via BAL for intraprocedural hemostasis. One hour after the procedure, he developed altered mental status, myoclonus, and hyperthermia, which was ultimately controlled with propofol and vecuronium. As the use of pulmonary tranexamic acid increases, toxicity from this agent should be considered. Dose reductions and alternate treatment modalities should be considered in patients with advanced age, arteriovenous malformations, and renal insufficiency.