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A woman in her 20s with no medical history presented to the emergency department with a 3-week history of shortness of breath. She denied any chest pain or fever. Her initial observations were pulse 90, SpO2 86%, temperature 37.0°C, BP 189/113 mmHg. Examination revealed widespread crackles. Bedside investigations included an ECG showing normal sinus rhythm and a venous blood gas showing a metabolic acidosis (pH 7.267, lactate 3.6). Her chest radiograph is shown in figure 1.