Pulmonary hemorrhage is one the less common causes of airspace consolidation, and can be superimposed on acute or chronic infection. This case demonstrates progression of the ground glass nodules in a centrilobular distribution within dependent portions of the lung over a week of ongoing hemoptysis, due to aspiration of blood products into the alveolar spaces.

The patient was treated for community acquired pneumonia, with concurrent tranexamic acid. Follow up CT chest 1 week later showed improvement in the right middle lobe consolidation and ground glass nodules. Further 2 weeks later, the patient underwent bronchial catheter angiography, with successful embolization of the right bronchial artery. The fistulous vessel supplying the right middle lobe was confirmed to arise from right internal mammary artery and demonstrated communication with the right pulmonary vein, so was not considered safe to embolize.

This appearance of bronchiectasis involving the right middle lobe and lingula is typical for Mycobacterium avium complex (MAC) infection (Lady Windermere syndrome). However, in this case, the patient had a known history of chronic bronchiectasis attributed to recurrent infections, but has not been shown to have Mycobacterial infection.