Percutaneous computer tomogram guided lung biopsy was arranged to confirm the suspicion of tuberculosis, but did not yield conclusive results. reviewed published cases of nocardiosis post-rituximab. Background The usage of rituximab in this patient had rendered her severely immunocompromised allowing the emergence of nocardia. In this era of biologics, all patients should have a sensible balance of risk and benefit. Case presentation We report a case of a 58-year-old retired lady, with a history of long-standing rheumatoid arthritis and who was managed previously on multiple immunosuppressive therapies. Her other co-morbidities include lung fibrosis, bronchial asthma, steroid-induced diabetes mellitus and Cushing’s syndrome, trigeminal neuralgia, dyslipidaemia and carpal-tunnel syndrome. She was given various types of disease-modifying antirheumatic medications; however, the disease remained uncontrolled. Despite the administation of cyclosporine, azathioprine and low-dose corticosteroid, her disease was still refractory to treatment. Rituximab was considered for administration, in view of Thiamet G the failure of treatment with the use of disease-modifying agent and vasculitis. As the disease became incapacitating, rendering the patient bedbound, rituximab had to be given. Two weeks after the second dose of the rituximab, she presented with fever, chest pain and dyspnoea. Chest radiograph revealed a left lower zone consolidation, and she was treated for nosocomial pneumonia subsequently. As she was bedbound and electrocardiogram showed changes suspicious of pulmonary embolism, CT pulmonary angiogram was performed. Alarmingly, it showed an intraparenchymal speculated mass in the subpleural region at the left upper lobe, measuring 126.96.36.199 cm, with central necrosis. Subsequently, a percutaneous, CT-guided, lung biopsy was performed with an 18G trucut biopsy needle. Histopathology examination of the lung nodule only showed interstitial pneumonia-like changes with fibrosis. No feature of granulomatous disease or fungal contamination was noted in the study. She presented again with pneumonia a month later. The chest radiogram showed comparable changes. The blood culture grew sp spp. She was treated with co-trimoxazole, for a period of 2 weeks. She responded to the medication and the fever decreased, with noticeable improvement in her condition. The wound healed with secondary healing. Histopathological examination of the left breast tissue showed chronic granulomatous inflammatory lesions. Investigations High-resolution CT Thorax showed 1A-intraparenchymal speculated mass seen in the subpleural region at the left upper lobe before the lung biopsy. 1B-Pectoralis major abscess with Thiamet G intraparenchimal Thiamet G lesion along the needling tract (physique 1). Open in a separate window Physique 1 (A) Intraparenchymal speculated mass seen in the subpleural region at the left upper lobe before the lung biopsy. (B) Pectoralis major abscess with intraparenchimal lesion along the needling tract. Fungal culture and sensitivity revealed nocardiosis spp. Differential diagnosis spp., spp. infections, Breast carcinoma. Treatment She was treated with 2 weeks of intravenous TMP-SMX and later continued with the oral form. Outcome and follow-up She was seen in the clinic 2 weeks later, but she was subsequently admitted for severe drug reaction. She was then discharged well. Discussion Deciding on which are the best investigations and treatment modalities is usually a difficult task. We described a case of pulmonary nocardiosis with needle tract seedling to the pectoralis major muscle after receiving rituximab for refractory rheumatoid arthritis. Rituximab, a B-cell-depleting monoclonal anti-CD20 antibody, was approved by the Malaysian Drug agency in 2007. There are limited local data on the side effect of rituximab. REFLEX1 has shown that serious infections occurred in only 5.2% of the patient population who received rituximab, compare to 3.7% of those in the placebo category. However, there was no report on occurrence of opportunistic infections during the 24 weeks of the study. According to Salliot sp., is a Gram-positive bacillus, aerobic actinomycetes in the genus sp., with partial acid-fastness. Partial acid-fastness is usually a unique characteristic of sp. that is not exhibited by other actinomycetes. There are more than 50 known species, and more than 50% of them cause infections in humans.3 However, spare known to cause infection predominantly in humanss.4 It is an opportunistic infection in immunocompromised patients. Its main route of acquisition is usually through aerosol, which explains why lungs are a primary site of contamination in more than two-thirds of cases reported.5 6 Other modes of infections are ingestion of contaminated food products and direct inoculation from trauma. In the case of our patient, she possibly acquired the infection through aerosol route, which later disseminated to the chest wall after needle lung biopsy. Nocardiosis occurs in people with depressed cellular immunity. The risk factors for acquisition of the disease are usage of long-term glucocorticoids, immunosuppressive therapy, underlying lung disease, lymphoproliferative diseases, transplantation, Thiamet G and AIDS. It Hpse is possible that our patient had already acquired the nocardiosis prior to initiation of rituximab. The immunosuppressive effects of rituximab.