A 35-year-old female presented to the chest physician with history of fever and breathlessness since 3 months associated with cough and expectoration. Symptoms aggravated since one week. She also gave history of pulmonary tuberculosis and was undergoing the treatment for the same (ATT category 2) since one month. She gave the history of previous surgery for psoas abscess. On examination, her pulse and blood pressure were stable. She was found to be in respiratory distress and there was evidence of right lower lobar pneumonia. Chest x ray showed right lower lobar collapse. Echo showed presence of mobile mass in roof of left atrium (LA) extending into mitral annulus. Mild mitral regurgitation (MR) was also noted. 
 MDCT chest showed consolidation with underlying cavitation of right lower lobe (Figure 1a). Extensive discrete and confluent lung nodules were noted bilaterally with tree in bud appearances (Figure 1b). There was thrombosis in right inferior pulmonary vein extending into left atrial cavity reaching upto the mitral valve (Figure 2). Other findings included splenomegaly and splenic infarcts. 
 Possible infection related thrombosis was thought and patient was started on anticoagulation. No evidence of endobronchial tuberculosis was noted bronchoscopically. Gene X-pert on bronchoalveolar lavage fluid was positive for myocobacterium TB and Rifampicin resistance was not detected. Patient was continued on category 2 ATT (daily regimen) along with IV antibiotics and supportive measures. Patient made a gradual improvement with treatment. Adequate anti-coagulation was achieved and was being discharged in a stable condition.