Pt DP after 4 yrs antifungal treatment coughed up hard black material

This man with chronic cavitary pulmonary aspergillosis, has been on continuous antifungal therapy for 4 years, initially itraconazole (with intracavity amphotericin B), then a short course of amphotericin B, then voriconazole with a period of interferon gamma, now posaconazole. He is co-infected with Mycobacterium xenopi, and has chronically abnormal liver function tests, of uncertain aetiology. Previously he coughed up plug-like material, and recently black hard material that is completely solid. This occurred following a 4 month period of sustained improvement on posaconazole (aspergillus precipitin titre has fallen from 1/32 to positive undiluted), but with relapsing M. xenopi infection

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