Arteriovenous fistula originating from a Rasmussen aneurysm: Beyond pulmonary tuberculosis

Life-threatening hemoptysis is a serious complication of cavitary pulmonary tuberculosis and can result from multiple coexisting mechanisms, including vascular lesions and chronic pulmonary aspergillosis (CPA), which is frequently missed in post-tuberculosis lung disease. Therefore, we present the case of a 23-year-old immunocompetent man with cavitary pulmonary tuberculosis who developed massive hemoptysis with hemorrhagic shock and acute respiratory failure requiring mechanical ventilation. Emergency angiography identified a arteriovenous fistula and a Rasmussen aneurysm of the right pulmonary artery, which was successfully treated with endovascular embolization using ethylene-vinyl alcohol copolymer, achieving immediate hemostasis. Further evaluation revealed concomitant pulmonary aspergillosis, supported by radiological findings and a positive galactomannan result on bronchoalveolar lavage. The antituberculosis treatment was modified to avoid rifampicin, and antifungal treatment with voriconazole was initiated, resulting in a favorable clinical course. This case underscores the multifactorial nature of life-threatening hemoptysis in tuberculosis-endemic settings and highlights the need for integrated vascular and infectious disease management to reduce recurrence and improve outcomes.