A young female patient presenting with recurrent hemoptysis, neck swelling, and mediastinal mass mimicking lymphadenopathy was admitted to the Institute of Post Graduate Medical Education and Research and SSKM hospital, Kolkata, India. Clinical features, radiological studies, fibre optic bronchoscopy, and fine needle aspiration cytology from the neck swelling created a diagnostic dilemma until surgical resection and immunohistochemistry reports confirmed the diagnosis of multifocal epithelioid hemangioendothelioma, a rare vascular tumor with intermediate malignancy potential. Because it is a slow-progressing disease and due to the non-availability of standard chemotherapy, the patient, and her legal guardian, opted for palliative care only. She was asymptomatic for four years but again presented with hemoptysis, reappearance of the neck swelling on the same side, and a mediastinal mass compressing the superior vena cava and right pulmonary artery. This report describes the diagnostic problems and therapeutic challenges in the management of this rare tumor over a four-year follow-up period. The clinical course emphasizes the highly unpredictable nature of this tumor.

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BACKGROUND Empyema thoracis refers to accumulation of pus in the pleural space. The pathogenic organisms isolated in cases of empyema depend on prior antibiotic use and route of infection i.e. whether infection arises as a complication of pneumonia or following oesophageal surgery. It also depends on the age of the patient and presence of co-morbid illness. MATERIALS AND METHODSIt is a descriptive study. It was designed to investigate the bacterial isolates of thoracic empyema and to find out the anti biogram pattern of the isolated organisms in a tertiary care hospital over one-year period. In this study, bacteriological spectrum was analysed in 50 empyema cases. Samples of pleural fluid were sent for bacterial culture (Aerobic) and for Gram's stain as well as for cytologic studies and mycobacterial and fungal smears and cultures, also if clinically indicated Cartridge Based Nucleic Acid Amplification test (CBNAAT). Patients with tubercular empyema were excluded. RESULTS24 cases were culture positive. Among the 24 culture positive cases, Streptococcus pneumoniae was the commonest bacterium isolated followed by Staphylococcus aureus. A strong inverse correlation was found between prior antibiotic use with chance of culture positivity. In present study Gram-positive organisms were found to be most sensitive to Vancomycin, Linezolid and some are sensitive to Clindamycin, Ciprofloxacin, Levofloxacin and Co-amoxyclav. Gram negative organisms were mostly sensitive to Ceftriaxone, Cefoperazone, Cefepime, Piperacillin-Tazobactam, Meropenem and Colistin. All the strains of Pseudomonas aeruginosa were sensitive to Amikacin. Resistance to Co-amoxyclav was noted in many strains of the Gram negative organisms except Klebsiella. CONCLUSIONGram positive organisms were the commonest organisms isolated in our study. This study also supports the view that prior antibiotic use reduces the chances of detecting the micro-organism through culture and determination of sensitivity.