In July 2020, a 48-year-old male presented with a "lung shadow of 1 week (1w) on physical examination" at the Fourth Affiliated Hospital, Zhejiang University School of Medicine, other hospital chest computed tomography (CT) results showed inflammatory lesions in the upper lobe of the right lung (exact report not available). The patient had no uncomfortable symptoms such as fever, cough, or hemoptysis, and thus he was given levofloxacin tablets as an anti-infection treatment. The results of the chest CT were re-examined after 10 days of treatment and revealed that mediastinal lymph nodes had calcification, the upper lobe of the right lung had a lamellar shadow with calcification, corresponding bronchial stenosis, and possibly chronic inflammatory lesions. The two lungs also had a few speckled and cord-like hyperdense shadows (Figure 1A and B). The patient had a history of hypertension, fatty liver, and abnormal liver function, with no history of glucocorticoids, cytotoxic drugs, or immunosuppressive therapy. Personal history: smoked 10 cigarettes per day for more than 20 years. 
He was admitted with a temperature of 36.8 C, a respiratory rate of 20 breaths per minute, a heart rate of 72 beats per minute, a blood pressure of 143/90 mmHg, and a body mass index (BMI) of 26.08 kg/m2. He was in a clear state of mind and had regular breath sounds in his lungs, no dry rales, and no pleural friction sounds on auscultation. Physical examination of the heart, abdomen, and peripheral vasculature revealed no obvious abnormalities. Immunoglobulin (Ig) and antibody results showed that IgG was 7.39 g/L  and complement protein C4 was 0.11 g/L . Biochemical results revealed that alanine transaminase was 63 U/L  and gamma-glutamyl transferase was 92 U/L . His routine blood test as well as other laboratory tests such as T, B, and natural killer lymphocyte subsets were normal. On the second day following admission, a bronchoscopy was performed. White pus was observed in the flushing of the right upper lobe lumen and a necrotic mass tissue was observed under a bronchoscope in the anterior portion of the right upper lobe (Figure 1C). The bronchial mucosa of the anterior segment of the right upper lobe was taken for pathological examination. Brushing and bronchoalveolar lavage fluid (BALF) examinations were also performed. Pathological biopsy showed fungal hyphae with necrotic calcification, the morphology was more consistent with Aspergillus (Figure 1D and E), indicating broncholithiasis and right upper lobe invasive aspergillosis. The BALF galactomannan (BALF-GM) test result was 1.4 mug/L (positive), fungal culture for Aspergillus fumigatus was found, bacterial culture was normal bacterial growth, Mtb DNA and tuberculosis (TB) smear examinations were negative, and no malignant cells were observed. The brush test results were also normal. A diagnosis of broncholithiasis and Aspergillus infection was made in conjunction with the examination results, and the patient was treated with voriconazole 200 mg bid antifungal therapy. Treatment was continued with oral voriconazole after discharge from the hospital. The chest CT was taken at each of the six follow-up visits, and the results revealed that the inflammatory lesions had been completely absorbed. During this period, the patient had no clinical symptoms and was in good general health.
A secondary bronchoscopy was carried out in February 2021 to determine whether to discontinue antifungal medication after six months of treatment. The patient was no longer prescribed voriconazole after BALF-GM test results and accompanying pathogenic smear and culture examinations were negative. In February 2022, one year after the termination of the voriconazole, the patient underwent one more examination, and a CT scan showed bronchiectasis in the upper lobe of the right lung, in which nodules with calcification were observed, measuring about 3.1x1.7 cm, which was larger than before. A faint lamellar shadow was seen next to the right lung hilar, and therefore infection was considered. Multiple foci of calcification were seen in the right lung hilar, and calcified lymph nodes were seen in the mediastinum (Figure 2A). Because the patient had no subjective symptoms despite these findings, suggesting that his condition was progressing, a third bronchoscopy was carried out. A stone-like mass was discovered in the anterior section of the upper right lung on bronchoscopy (Figure 2B), and white pus was seen on flushing. Bronchoscopic stone extraction failed because the stone was firmly attached to the tracheal wall and could not be moved or totally detached. Mucosal biopsy pathology showed chronic inflammation of the mucosa with calcification (Figure 2C). BALF revealed that erythrocytes were >100/Hp, nucleated cells were 6-10/Hp, the neutrophil percentage was 92%, and fungal culture was negative, and the rest of the bacterial smear and bacterial culture results were not abnormal. The final diagnosis was as follows: (1) broncholithiasis and (2) obstructive pneumonia; hence, the patient was given cefixime for anti-infection. After a month, the chest CT was retested, and the results showed a good prognosis.