A 69-year-old never-smoker was referred to a lung cancer assessment clinic in June 2022 with 4 weeks of exertional breathlessness, haemoptysis and fever, persisting despite three antibiotic courses. Medical history included a kyphoplasty and paroxysmal atrial fibrillation (PAF) requiring radiofrequency catheter ablations in July 2019 and February 2022.

He had a previous episode of fever and haemoptysis in December 2019. Chest X-ray showed left basal consolidation and a small pleural effusion, with subsequent symptomatic and radiological resolution after antibiotics.

At presentation to the lung cancer assessment clinic, blood tests revealed a C-reactive protein of 32 and weakly positive p-antineutrophil cytoplasmic antibody. Chest X-ray showed an opacity in the right lower zone (figure 1), and subtle pleuroparenchymal shadowing at the left base.

Chest X-ray on initial referral (left) and after 4 weeks (right) showing a right middle lobe nodule (arrow) and …