We discuss a interest case of an elderly male from Mexico with risk factors for stone cutting presenting with a worsening dry chronic cough in setting of newly diagnosed HCC. Chest CT shows numerous centrilobular and perilymphatic nodules and calcified mediastinal lymphadenopathy. Our differential for “random” (perilymphatic & centrilobular) is broad.

Our patient underwent endobronchial ultrasound guided transbronchial needle aspiration + BAL with Cone Beam CT guided Transbronchial Cryobiopsy. Results showed silicosis and pulmonary Cryptococcus.