The patient was a young housewife originally from north Iran. Her illness started 30 days ago with fever, night sweats, weakness, and weight loss of four Kg, that followed with productive cough and hemoptysis, about 20 cc of blood in her sputum for 3 times. She had a normal delivery 5 months ago with a normal infant. She is a nonsmoker, without any history of recent travel or drug abuse. She had no significant medical history except an episode of pyelonephritis when she was 6 years old, recurrent oral aphthous ulcers, and multiple episodes of common cold in the last two years. She had four healthy, living siblings and her parents were not related. Her aunt had pulmonary tuberculosis twenty years ago. 
On admission she was dyspneic and febrile with oral temperature of 39 C. Her blood pressure was 110/60 mm Hg, heart rate was 120/min, and respiratory rate was 20/min. Physical examination was unremarkable except pectus excavatum and bilateral course crackles along with rhonchi in right hemithorax. Peripheral blood leukocyte count was 16300/muL with 65% neutrophil, 10% lymphocyte, 11% monocyte, and 14% eosinophil (total eosinophil count: 2282/muL); hemoglobin and platelet counts were 8.6 mg/dL and 552 x 109 per liter. The erythrocyte sedimentation rate was 125 mm/h. All results of biochemical tests were normal. Also c-ANCA, p-ANCA, anti-PR3 IgG, and anti-MPO IgG were negative.
A chest X-ray was done and showed cavitary lesions and nodules in both lungs. Direct smear of sputum for acid fast bacilli was negative three times. Ciprofloxacin and meropenem were started but no improvement was seen in her condition.
The thorax CT scan was performed and showed biapical cavitary lesions and intracavitary soft tissue projection in the left lung. Also scattered nodular infiltration with a large mass-like consolidation was seen in the right lower lobe. Right hilar and subcarinal adenopathy there also reported (Figure 1).
Bronchoscopy was done which showed a necrotic obstructive mass at the right middle bronchus. No bacterial or fungal agents were isolated from sputum and bronchoalveolar lavage (BAL) fluid. Histopathological study showed filamentous septated hyphae with acute angle branching, without any evidence of granuloma or necrotizing vasculitis. Galactomannan assay index of serum was highly positive (10 ng/mL). Voriconazole was added to her treatment.
 Aspergillus fumigatus was isolated from the culture of tissue specimen. Bronchoscopy was repeated for the removal of obstructive mass. Distal to it, a lot of necrotic material was discovered (Figure 2). Voriconazole was changed to Itraconazole 200 mg t.i.d after seven days of treatment. Brain CT scan was performed and was normal.
The patient's immune system was assessed. Ranges of the immunoglobulins were normal. The nitroblue-tetrazolium (NBT) test was 0%. Also the dihydrorhodamine 123 (DHR) assay confirmed the diagnosis of chronic granulomatous disease (CGD).
Patient's symptoms improved gradually, fever stopped, and she did not have any episodes of hemoptysis at all. Therapeutic dose of Itraconazole was continued for four months, after that it was prescribed as 100 mg once daily concomitant with Trimethoprim-sulfamethoxazole as prophylaxis up to now. Also at the follow-up visits there was no sign of recurrent infection. Screening of the other members of the family was negative for CGD.