Cryptic case: 'It started with a pain in the ‘bum’, doctor'

Jasminsajna Mytheen Sahib, Lacey Sandra, Chakravarty Kuntal BHR University Hospitals NHS Trust, Romford, Essex, UK A 71-year-old male presented to A&E with a high fever, raised inflammatory markers and a gluteal abscess requiring incision and drainage. He had a history of prolonged treatment with immunosuppressive drugs for a pANCA positive systemic vasculitis with renal and pulmonary involvement. Previously, CMV was detected in a bronchoalveolar lavage (22,633genomic copies/ml) and blood (1996 genomic copies/ml) and he had been treated with oral valganciclovir. Incision and drainage of the gluteal abscess revealed gram positive branching rods. Two weeks later he developed cough, dyspnoea and fever. Pus from the gluteal abscess grew **********and CT imaging showed multiple lung abscesses. Although asymptomatic, a CT brain scan revealed a right parietal cerebral abscess. Empirically he was treated with intravenous co-trimoxazole and imipenem which was subsequently switched to meropenem. After six weeks of intravenous treatment, he was switched to oral co-trimoxazole and azithromycin based on MIC susceptibility testing. Six months later the patient was systemically well and repeat CT imaging revealed resolution of his lung abscesses and regression of his brain abscess. His gluteal abscess fully healed and he remains on co-trimoxazole and azithromycin maintenance therapy. ************ should be considered in the differential diagnosis of soft tissue infections in immunocompromised patients. Brain abscess can be asymptomatic and imaging of the brain should be performed when disseminated disease is suspected. Prompt diagnosis and antimicrobial treatment reduces mortality. Although there is no guidance on combinations and duration of treatment, prolonged antimicrobials therapy can improve outcomes. Diagnosis: Nocardia novia