A 27-year-old Indonesian male visited his cousins in the U.S (Ohio) but ended up going to the ER for complaints of hemoptysis and fevers. He has been coughing for the past 3 weeks, and noticed reddish sputum yesterday for the first time. He has also noted a 7 lb. unintentional weight loss within the last 3 weeks. Routine labs show no acute abnormalities, however a chest X-ray shows a right middle lobe cavitary lesion. He is placed in airborne isolation, a PPD is checked and found to be negative. Acid Fast Bacillus (AFB) smears return negative from expectorated sputum as well. Cultures are pending for AFB, however. He is placed on TB therapy empirically but continues to do poorly in the hospital 4 days later. On day 7, his hemoptysis worsens, and he requires intubation for airway protection. CT of the chest now shows 2 cavitary lesions in the right mid/right lower lung area.

He has a 7 pack-year history of smoking, but otherwise has no known medical issues except for seasonal allergies. There is a family history of COPD in his uncle and grandfather (both of which smoked). He has 1 cat at home in Indonesia, drinks bottled water there (no tap water), denies drug use and drinks 1-2 beers a week with friends. He enjoys seafood, and consumes crabs, shrimp and other shellfish in Indonesia quite regularly. His mother was recently sick with a URI, but she is doing well now. HIV testing is negative, as is Cryptococcal antigen. Repeat CBC w/differential is only significant for a mild eosinophilia. A bronchoalveolar lavage (BAL) is then performed, and is negative for bacteria and fungi. Legionella and Strep pneumoniae urinary antigens are both negative. Blood cultures x 2 sets are negative as well. A repeat BAL is done 48 hours later, biopsies are taken which revealed the diagnosis.

Based on the above information, what is the most likely diagnosis?

1. Mycobacterium avium
2. Histoplasma dubosii
3. Fasciola hepatica
4. Aspirated crab shell fragments
5. Bronchoalveolar lung cancer
6. Paragonimus westermani
7. Strongyloides stercoralis