A 60-year-old man presented with a 2-week history of productive cough associated with rigours and sweats. He was a 55-pack-a-year smoker, on hydroxycarba-mide for idiopathic polycythaemia, with a history of hypertension and alcohol excess. Chest radiography showed patchy consolidation (Figure 1). He developed respiratory failure and acute lung injury despite treatment for community acquired pneumonia and escalation of antibiotic therapy. Computed tomography showed a widespread inflammatory process with multilobar collapse, patchy consolidation and peribronchial infiltrates especially in the right upper lobe (Figure 2). Bronchoscopy revealed diffuse white slough mucosal patches throughout the tracheobron-chial tree but most prominent around the right upper lobe subcarina. Bronchoscopic biopsy of the slough revealed multiple fungal septate hyphae in ulcer slough consistent with aspergillus (Figure 3), which was also identified on immunofluorescence on broncho-alveolar lavage. Systemic amphotericin treatment was initiated. The broncho-alveolar lavage culture subsequently confirmed as fully sensitive aspergillus and a positive galactomannan antigen. Despite intensive treatment, the patient deteriorated and died after 9 days with multi-organ failure. Particular risk factors for invasive aspergillosis in this case were the hydroxycarbamide and alcohol excess.
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