CASE PRESENTATION: 59 year old male with prior tobacco abuse, presented with two months of progressive dyspnea, cough, and fevers despite antibiotics. CT demonstrated a mediastinal mass with compression of the left mainstem bronchus, mediastinal lymphadenopathy, and cavitary consolidation of the left lower lobe. A necrotic endobronchial mass causing 80% obstruction of left mainstem bronchus was visualized on bronchoscopy. Biopsies revealed inflammation without evidence of malignancy. Bronchial cultures and cytology were initially unremarkable. Diagnostic endobronchial ultrasound and fine needle aspiration of mediastinal lymph nodes revealed granulation tissue with suppuration. HIV, tuberculous, and fungal serologies were negative. Patient was discharged home, but represented sixteen days later for headache and confusion. Original bronchial cultures now showed light growth of Nocardia, and cerebral imaging was consistent with intracranial abscesses. Emergent craniotomy and abscess drainage revealed frank purulence and intraoperative cultures were also positive for Nocardia beijingensis. He was treated with IV trimethoprim-sulfamethoxazole (TMP-SMX) and IV meropenem for 8 weeks, followed by oral TMP-SMX monotherapy for 12 months. Chest and brain imaging one year later showed no evidence of recurrent disease.