Empyema thoracis due to Nocardia otitidiscaviarum.

We read with interest the article on pulmonary nocardiosis in southern Taiwan by Chen et al. In their study, eight of the 20 patients with pulmonary nocardiosis had pleural effusion and three of these patients had empyema thoraces. Among these three nocardial empyema cases, the authors reported a 61-year-old man with diabetes mellitus and chronic liver disease suffering from an acute course of empyema caused by Nocardia otitidiscaviarum. N. otitidiscaviarum is a rare pathogen among nocardial infections and pulmonary nocardiosis. We herein present another case of N. otitidiscaviarum empyema after a short course of corticosteroid for inflammatory arthritis. A 42-year-old man with alcoholic liver cirrhosis, ChildeTurcotteePugh score B, presented with esophageal varices bleeding initially. On the 8 day after admission, a 5-day course of corticosteroid with hydrocortisone (100 mg intravenously every 12 hours; equivalent dose Z 50 mg prednisolone/day) was prescribed for inflammatory arthritis of bilateral knees. The dose of corticosteroid was then tapered to 20-mg prednisolone daily. On the 15 day, fever with shaking chills and purulent coughwere noted. The chest X-ray revealed right lower lobe infiltrate, and within a day the right pleural effusion developed rapidly. Results of the pleural effusion study revealed the presence of exudate (pleural effusion/serum protein, 4.0/7.2 g/dL; pleural fluid/ lactate dehydrogenase, 915/153 IU/L) with a cell count of 8653/mm and a predominance of polymorphic neutrophils (polymorphic neutrophils/monocytes: 87%/13%). No microorganism was identified with Gram staining and acid-fast staining of the pleural effusion. An antibiotic combination of piperacillinetazobactam and vancomycin was used for treatinghospital-acquired pneumonia. The clinical condition deteriorated and the patient was intubated on the 8 day after symptom onset. Because of a poor response to medical therapy, video-assisted thoracoscopic surgery (VATS)