Recurrent pneumonia with brain lesions

A 53-year-old male, had had mitral valve replacement in 2008 for mitral stenosis and myasthenia gravis, on steroids and azathioprine, presented with clinical and radiological features of recurrent pneumonia involving the same area of the lung, 2 months apart (Figs.1a-d).He was managed as a case of community-acquired pneumonia.Subsequently, he developed giddiness, projectile vomiting, and occipital headache.Contrast-enhanced CT brain showed a ring-enhancing multiseptated lesion measuring 9 16 14 mm in the left occipital lobe (Fig. 2).He underwent a video bronchoscopy and bronchoalveolar lavage (BAL).Modified Ziehl-Neelsen stain showed thin filamentous acid-fast bacteria (Fig. 3).