A 26-year-old male pre-operative transsexual presented to the emergency dept of the University of Texas Southwestern Medical Center (TX, USA) with complaints of acute dyspnoea and frank haemoptysis. The patient did not use intravenous or illicit drugs, alcohol or tobacco, but had a history of unprotected homosexual intercourse. On physical examination, the patient was in severe respiratory distress, with a respiratory rate of 38 breaths per minute and accessory muscle use. The physical examination revealed subcutaneous emphysema, diffuse bilateral crackles, and mediastinal crepitus consistent with a Hamman's crunch. The patient had decreased facial and body hair, moderate breast augmentation and male genitalia.
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