INTRODUCTION: Cushing Syndrome (CS) is a condition of hypercortisolism due to adrenal disease or an ACTH secreting tumor. Associated hypercoagulability and immunosuppression create the potential for venous thromboembolism and opportunistic infection, respectively. CASE PRESENTATION:We present a case of a 47-year-old man with hypertension and diabetes who presented with encephalopathy. MRI showed pituitary macroadenoma. He was diagnosed with Cushing's disease and underwent successful resection of this mass. However, post-operative cortisol levels did not fall as expected thus bilateral adrenalectomy was performed.His hospital course was complicated by acute pulmonary embolism and left sided pleural effusion of unclear etiology leading to respiratory compromise. He subsequently developed a spontaneous hydropneumothorax which did not resolve despite placement of multiple pigtail chest tubes. CT chest showed cavitary pneumonia, and the pneumothorax and associated empyema were attributed to rupture of this infected area. Pleural fluid culture data revealed Nocardia pseudobrasiliensis and a new MRI brain showed cerebritis and left temporal lobe abscess.The patient received meropenem and trimethoprim-sulfamethoxazole (TMP-SMX) and ultimately required left thoracotomy with left lower lobectomy. He improved and was discharged to acute rehabilitation.DISCUSSION: Cushing's disease describes CS due to an ACTH producing pituitary tumor. Manifestations include insulin resistance, hypertension, and cushingoid appearance. It also causes hypercoagulability and immunosuppression by increasing production of clotting factors, decreasing fibrinolysis, and impairing neutrophil and macrophage recruitment to infection sites (1, 2). Nocardia infection typically occurs in immunocompromised patients, such as those with HIV, malignancy, and CS (3). Pulmonary Nocardiosis is typically due to direct inhalation of the organism and often associated with cavitary lung lesions. Extrapulmonary Nocardia is characterized by abscess formation with the central nervous system (CNS) being the most common extrapulmonary site. CNS imaging is recommended in all patients diagnosed with Nocardia pneumonia, especially in those with neurologic symptoms (3). For patients with CNS involvement, antibiotic duration is at least one year and should include TMP-SMX with a carbapenem or ceftriaxone, to be de-escalated to TMP-SMX monotherapy after clinical improvement. Secondary prophylaxis with daily TMP-SMX is recommended (3). CONCLUSIONS:Nocardiosis is an important opportunistic infection to consider in immunocompromised patients. Pulmonary infection commonly involves cavitary lesions and the possibility of CNS involvement must be considered in every case of Nocardiosis.

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