Tuberculosis Quiz: Ace Your Exams

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A 46-year-old female presents to the emergency department with complaints of fever, cough, and night sweats over the past 2-3 months. Past medical history is notable for HIV infection, type II diabetes mellitus, and hypertension. She is currently undomiciled, drinks 3-4 alcoholic drinks per day, smokes one pack of cigarettes per day, and uses intravenous heroin daily. Temperature is 37.2 °C (99.0°F), pulse is 87/min, respirations are 16/min, blood pressure is 156/74 mmHg, and O2 saturation is 95% on room air. Physical exam demonstrates a thin, cachectic middle aged female with track marks noted on the upper extremities bilaterally. Cardiopulmonary exam reveals rales in the upper lobe of the left lung, without gallops, rubs, or murmurs. Chest x-ray is demonstrated below.  

 
Image reproduced from Radiopaedia  
Which of the following is the most important contributing factor for the development of this radiographic finding?  

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