Pulmonary tuberculosis is most common cause for bilateral pulmonary cavities with constitutional symptoms in India being endemic and more prevalent nature of disease, irrespective of microscopy or nucleic acid amplification test abnormalities. Pulmonary manifestations of systemic vasculitis have very diverse involvement ranging from nodule, consolidation, and cavitation. In this case report, 49-year female, presented with constitutional symptoms with lung parenchymal consolidations progressed to cavitation’s and started empirical anti-tuberculosis treatment without mycobacterial microscopic or genome documentation in sputum with clinical or radiological worsening. Bronchoscopy workup is inconclusive and tropical screen for bacterial, TB, and malignancy were negative and fungal yield aspergillus colonization. Vasculitis workup done in presence of clinical and radiological worsening documented PR3-ANCA positive with very highly raised titers. We have started on steroids, cyclophosphamide with antifungals and clinical response documented with near complete resolution of shadows in 24 weeks. She had developed DVT (deep vein thrombosis) lower limb during course of illness and documented excellent response to anticoagulation. DVT prophylaxis is must in all cases taking steroids with decreased daily activities to prevent fatal cardiovascular complications.