CASE VIGNETTE

A 41-year-old man with a one-month history of fever, progressive painless skin ulcers over both upper and lower limbs (Fig 1A), with a past history of pulmonary tuberculosis (2016) for which he completed 6 months of anti-tubercular therapy, and a history of rheumatic heart disease. Echocardiography revealed a large calcified mitral valve vegetation (22×16 mm2). An extensive work-up was performed, which included repeated blood cultures, autoimmune serology (ANCA, ANA), and a skin biopsy, which were negative for any organism or vasculitis. CECT thorax showed a fibro-cavitary lesion with an air-crescent sign in the right upper lobe (Fig 1B), while the Aspergillus-specific IgG was ,markedly elevated at 48.20 (reference range < 27 mgA/L). Over the course of the hospital stay, the vegetation spontaneously decreased in size (22×16 mm2 to 8×13 mm2), and the skin ulcers healed without antibiotic or antifungal treatment. . There was subsequent massive hemoptysis, which ultimately required lung resection; histopathology confirmed Aspergillus species.

Figure 1: Skin ulcer (A) and CT findings of chronic cavitary pulmonary aspergillosis (B)

 ANSWER: The answer will be released in the upcoming September 2026 issue.