A 50-year-old ex-smoker has been complaining of a 5-month history of morning cough that is productive of small amounts of discolored phlegm, fever, a 10-pound weight loss, fatigue, and a lesion on his face (Figure 1
). The lesion drains, tends to heal over for a few days, then breaks down and discharges pus containing sand-like yellow-to-white particles. The patient, who had undergone coronary artery bypass graft surgery 5 years before, takes no medications, admits to drinking two glasses of wine each night, and has no other complaints other than that his gums occasionally bleed when he brushes his teeth. Physical examination reveals a temperature of 38.2°C, blood pressure 140/80 mm Hg, pulse 84 beats/min, respirations 26 breaths/min, and crackles heard over the anterior portion of the right chest. A chest radiograph is obtained (Figure 2
). The metal clips in the mediastinum are incidental findings from a prior coronary artery bypass operation. Which of the following diseases does the patient most likely have?