A Rare Case of Chest Wall Abscess by Nocardia in a Patient With Sarcoidosis.

Nocardia is a rare gram-positive pathogen reported to cause infections in immunocompromised individuals. It usually involves the lungs but may also lead to abscess formation; cases of disseminated nocardiosis have also been reported. We are presenting a case of an Asian male who had sarcoidosis with pulmonary and skin involvement. The patient was on long-term immunosuppressive therapy with corticosteroids with good control of the disease. He developed a fever, weight loss, and right-sided chest pain. CT of the chest showed new nodular infiltrates. Worsening of sarcoidosis was suspected; the corticosteroid dose was increased and methotrexate was started. There was no favorable response to the increase in immunosuppressive therapy. Weight loss was followed by worsening shortness of breath and fluctuant swelling in the right lateral half of the chest. Bronchoalveolar lavage was done to rule out tuberculosis but it did not show any organism's growth. Ultrasound-guided needle aspiration from the abscess was done that showed growth of Nocardia species. Therapeutic dose co-trimoxazole (trimethoprim-sulphamethoxazole) was started as first-line therapy after confirming the organism's drug susceptibility pattern along with needle aspiration of the collection on the chest wall. Immunosuppressive agents were stopped. There was a good response to treatment with resolution of symptoms within two months. However, complete radiological recovery took 10 months. Co-trimoxazole (trimethoprim-sulphamethoxazole) therapy continued for two months after radiological recovery. Physicians, therefore, should keep Nocardia as an important differential diagnosis while treating the immunosuppressed population.

Unusual case of bilateral haemotympanum after endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA).

We present a case of bilateral haemotympanum (HT) during endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA). A 64 year-old-man underwent EBUS-TBNA for mediastinal lymph nodes (LN) staging. Medical history included emphysema and angina. Medication included aspirin until the day before procedure. Full blood count and clotting screen were normal. He received sedation (5 mg midazolam, 1000 mcg alfentanil) and topical anaesthesia (16 mL 1% lignocaine) but coughed excessively throughout the procedure. Left hilar LN was the only area sampled. Spontaneous bleeding ensued from both ears towards the end of the procedure. Patient remained haemodynamically stable. The procedure was aborted and otolaryngology consult sought. Otoscopy showed bilateral haematoma from anterior ear canal with normal tympanic membranes and no hearing loss. Nasendoscopy revealed erythematous ostium of both Eustachian tubes. Bleeding stopped spontaneously and patient required no further imaging or treatment. We report this case to increase awareness of this very rare complication resulting from excessive coughing during EBUS-TBNA.