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A 45-year-old Indian man with a history of achalasia presented with fevers, cough and fatigue. He had undergone endoscopic dilatation for achalasia several years prior. Chest radiograph revealed a dilated oesophagus and a left perihilar opacity (figure 1). He was treated for community-acquired pneumonia with a course of clarithromycin but had persistent cough, fatigue and weight loss with non-resolving radiographic infiltrates. A 3-week course of amoxicillin clavulanate was prescribed for suspected aspiration with little clinical improvement, and a chest CT was performed (figure 2). The patient had never smoked and had moved to the USA from India over 20 years ago, last travelling to India 1 year prior. Prior purified protein derivative skin tests (PPDs) were negative. HIV testing was …
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