The Cavity That Came Back

A 54-year-old man from Lima, Peru presents to the emergency department after coughing up approximately 50 mL of frank blood. He was treated for pulmonary tuberculosis eight years ago with a standard six-month regimen of rifampin, isoniazid, pyrazinamide, and ethambutol and was declared cured, with residual right upper lobe fibrocavitary scarring on follow-up imaging. He has a 30 pack-year smoking history but no other medical problems and takes no medications.

Over the past four months he has noticed progressive daily productive cough, drenching night sweats, fatigue, and a 12-kg unintentional weight loss. Six weeks ago he had a single episode of blood-streaked sputum that he attributed to coughing. He did not seek care until the larger bleed three days ago. At a local clinic three weeks ago, tuberculosis recurrence was suspected; three consecutive sputum acid-fast bacillus smears were negative and a single Xpert MTB/RIF was negative. A course of amoxicillin-clavulanate produced no improvement.

On examination his temperature is 37.6 °C, heart rate 94/min, blood pressure 118/74 mmHg, respiratory rate 18/min, and oxygen saturation 95% on room air. He appears cachectic (BMI 18.2). Coarse crackles are present over the right upper lung field. There is no lymphadenopathy, no clubbing, and no peripheral stigmata of endocarditis. He is not immunosuppressed.

Laboratory studies show a peripheral white blood cell count of 9.4 × 10³/µL with 64% neutrophils (no neutropenia), hemoglobin 11.4 g/dL, platelets 312 × 10³/µL, and C-reactive protein 78 mg/L. HIV serology is negative. Serum Aspergillus galactomannan is 0.2 optical density index (negative, cutoff < 0.5). A contrast chest CT is obtained and is shown below.