A 54-year-old woman was referred to our hospital for assessment  of 'multiple round cystic opacities varying in size' seen on a chest  radiograph (Fig. 1A and B) and a concern for possible lung malignancy.  She had been a homemaker for many years in a rural area of Eastern  Cape Province, with extensive exposure to indoor biomass fuel, and had  close contact with dogs, cattle and sheep. She presented with a 6-month  history of daily cough, productive of half a cup of yellow/green sputum  that had become white over the past month. She had noted haemoptysis  on only two occasions during the first month of cough. She described  seeing white 'eggshell membrane'-like substances in her sputum over  several months. During the same period, she experienced shortness of  breath on exertion, wheeze that was worse at night, central sharp chest  pain that radiated to both arms, and left upper-quadrant (LUQ) that  was worse when lying down on her left side. Constitutional symptoms  included weight loss (15 kg), with no associated loss of appetite, and  night sweats that were profuse at the start of the symptoms, with  associated fever and chills. These symptoms subsided somewhat after  two courses of antibiotics. 
 She was a non-smoker and had no history of tuberculosis (TB);  previous investigations for TB were negative (GeneXpert (Cepheid,  USA) and auramine stain). She recalled being diagnosed by a local  doctor, with two abdominal masses on ultrasound examination, but  defaulted on her appointment at a tertiary centre to which she had been  referred. 
 On physical examination, she had a blood pressure of 118/80 mmHg,  heart rate of 80 bpm and respiratory rate of 22 breaths per minute,  with saturation of 94% in room air. She was comfortable and weighed  50.0 kg (body mass index (BMI) 20.8). A general examination was  normal, and her respiratory examination revealed a trachea deviated  to the right and dullness in the right upper and lower zones, with  decreased breath sounds in the right lower zone. She had bronchial  breathing globally with no wheeze or crackles. Her abdomen was soft  and non-tender, with no ascites. She did have mild hepatomegaly and  an 8 - 10 cm firm mass in the LUQ. 
 On further investigation, her enzyme-linked immunosorbent assay  (ELISA) HIV test was negative and a full blood count revealed a mild  microcytic anaemia (Hb 10.7 g/dL, mean corpuscular volume 78.3 fL,  mean corpuscular Hb concentration 25.2 pg, white cell count 7 230/muL,  platelet count 5 810/muL) and elevated lactate dehydrogenase (248 U/L). She  had normal liver enzymes, international normalised ratio (INR) and renal  function (total protein 85 g/L, albumin 35 g/L, total bilirubin 4 mumol/L,  conjugated bilirubin 2 mumol/L, aspartate transaminase 20 U/L, alanine  transaminase 15 U/L, alkaline phosphatase 95 U/L, gamma-glutamyl  transferase 19 U/L, INR 1.30, urea 3.7 mmol/L, creatinine 76 mumol/L). 
 Sputum-microscopy sensitivity and culture revealed +3 neutrophils  with normal respiratory flora. GeneXpert was negative for Mycobacterium tuberculous. Pulmonary function tests demonstrated mild obstruction  with significant and complete reversibility after administration of a  bronchodilator (260 mL; 19%) and normal diffusion capacity (forced  expiratory volume (FEV1 ) 1.37 L (63% predicted), forced vital capacity  (FVC) 2.02 L (79%), FEV1 /FVC 67.69%, and carbon monoxide transfer  factor 16.42 mL CO/min/mmHg (75% predicted)). 
 The chest radiograph (Fig. 1A) showed right upper-lobe volume loss  with the trachea deviated to the right, crowding of ribs, right upper-zone patchy opacity with possible intracavity mass with crescent of  air and marked pleural thickening, large posterior right lower-lobe  round opacity (Fig. 1B) and smaller right middle-lobe round opacity  with marked bronchial wall thickening but no pleural effusions. The  most likely diagnosis was hydatid disease in an endemic area. Other  diagnostic considerations included lung  cancer, sarcoma or aspergilloma, for which a  computed tomography (CT) scan of the chest  was done as a further investigation. A CT scan  of the chest (Fig. 2A) revealed a large right  lower-lobe cyst (8 x 8 cm), with significant  right middle- and upper-lobe scarring,  traction bronchiectasis/bronchiolectasis  and lung cavities containing low-density  material with gas locules, in keeping with  aspergillomas. The left lung had a small well-circumscribed superior lingual cyst (19 mm),  while the upper abdomen (Fig. 2B) revealed  two large cysts in the liver (9.5 x 7.0 cm)  and spleen (15 x 10 cm). The final diagnosis  was hydatid disease of the lungs, with a rare  giant splenic hydatid, while the right upper-and middle-lobe disease was possibly due  to post-TB lung disease with aspergillomas  and/or bronchiectasis. The thoracic surgeons  recommended surgical removal of the cysts,  which the patient declined, citing a need  to consult further with her family. A trial of  medical treatment (albendazole 400 mg twice  daily) was commenced while awaiting surgery.  The patient later became loss to follow-up.