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Step 1: View clinicals

A 40 year old man is referred by his primary care practitioner after his hemoglobin level is found to be 9 g/dl. He had originally presented with lightheadedness and fatigue. Further questioning reveals a history of intermittent episodes of hemoptysis for the last 4 to 5 weeks. His medical history is significant for successfully treated pulmonary tuberculosis 6 years ago. No other comorbidities are present, and he has never smoked.

Step 2: Order all relevant investigations

Chest X-Ray

A heterogeneous opacity is present in the left upper lobe.

Contrast CT Chest

The CT shows a cavitatory lesion in the left upper lobe, with a mass lesion inside.

Precipitin Antibodies

He tests positive for Aspergillus precipitins.

Bronchoscopy + Lavage

Bronchoscopy: no abnormalities Cytology: no malignant cells noted Microscopy: Silver staining reveals multiple hyphae which branch at acute angles, suggestive of aspergillosis.

Step 3: Select appropriate management

Antituberculous Therapy
Surgical Resection
IV Miconazole

Score: ★★☆