A 26-year-old nonsmoking man was brought to the hospital for an episode of hemoptysis. On initial evaluation, a heart murmur was noted, and an echocardiogram showed mitral regurgitation. Chest radiography demonstrated a hydropneumothorax, prompting consultation to our service. Further history revealed intermittent production of blood-tinged sputum for the past 10 years. He described skin lesions on his right arm persisting over the last 4 years. On review of systems, he denied dyspnea, chest pain, fevers, night sweats, weight loss, and loss of consciousness. He also denied any history of recent trauma or practice of full contact sports. His father died suddenly at age 40 of unknown cause, and other paternal non-nuclear family members had cardiovascular events at young ages. He is currently enlisted in the armed forces and denies any exposure to dusts, chemicals, or asbestos. He has no risk factors for HIV, and he denies use of illicit drugs. His travel history is significant for a tour of duty in Panama.