Case Reports on Pleural Nocardiosis

Introduction: Most common causes of pleural effusion are tuberculosis, malignancy, congestive cardiac failure and rarely rheumatoid arthritis. Pleural effusion in connective tissue diseases can be due to disease itself, infection like tuberculosis and rarely malignancy. We need to differentiate the pleural effusion caused by disease or due to infection as treatment differs for both. Tuberculosis is endemic in our country and we tend to forget the rare causes of pleural effusion. Here we are presenting 2 cases of non resolving pleural effusion in connective tissue disease patients who were on long term immunossuppression and steroids. Case 1-45/ female, known case of SLE, on immunosuppressants for 2 years. Patient presented with cough and breathlessness. Chest radiography showed right pleural effusion, pleural fluid analysis showed exudative fluid, most likely tuberculosis. However patient did not took anti tubercular treatment and presented after one month with recurrent pleural effusion. Usg thorax showed loculated pleural effusion and done usg guided thoracocentesis. Frank pus aspirated, then put pigtail for drainage. Case 2-32/male, known case of Rheumatoid arthritis for 8 years, presented with cough and breathlessness for 20 days. Chest radiography showed loculated massive pleural effusion. Usg guided thoracocentesis done, frank pus aspirated. Hence Intercostal tube had inserted. Results: Both patient?s fluid report were exudative with very high values of ADA and LDH. ZN stain was negative, but Gram stain showed gram positive filamentous bacilli. Modified ZN stain picked up nocardia species. Both patients are on Cotrimoxazole for 6 months. Chest xray showing clearance and symptomatic improvement for both patients. Conclusion: Nocardia usually affects immunocompromised patients. Hence with high index of suspicion we have to approach and come to diagnoisis as nocardia usually affects lung parenchyma without involving pleura. Pleural involvement with nocardia is very rare, so in any undiagnosed case of pleural disease on prolonged steroid and immunosuppressant drugs, routine search for nocardia should be done. Here in both of our patients, there is mere involvement of pleura without involvement of lung parenchyma.