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Case of the Month - August 2014

Rispah Chomba and Warren Lowman

Male, 38 yrs old, previous pulmonary TB in 2009 treated for 6 months. HIV diagnosed in Aug 2010 when he presented to the surgeons with a chest mass and draining sinus. He was treated with 9 months of TB therapy despite negative cultures, and started on ART (TDF, 3TC, EFV).

In March 2011 he was re-admitted with cough, chest pain radiating to the back and right cervical lymphadenopathy. A fine needle aspirate of the nodes was performed.

Aspirate MC&S grew a Nocardia spp identified on 16SrRNA sequence analysis as N. brasiliensis

MIC testing (by broth microdilution [BMD]) showed the following susceptibility:

Amoxicillin-clavulenate (MIC 4µg/ml)Clarithromycin
Linezolid Ciprofloxacin (intermediate, MIC = 2µg/ml)

The patient was allergic to TMP-SMX and was treated for 5 weeks with amikacin and ceftriaxone (the reasoning behind the choice is unknown), and discharged home on amoxicillin-clavulanate 625mg TDS.

Three months later, his outpatient notes state that the sinus on chest wall now closed but patient has a central neck mass. Goitre? Cyst? Patient noticed increasing size over last 6 days. Patient referred to the surgeons. Ultrasound revealed a complex cystiEDc mass in the left lobe of thyroid most likely infective. Over the next week the anterior neck swelling enlarged with associated dysphagia and dyspnea.

On examination, he was wasted, afebrile, with a tender, enlarged goitre and generalized shotty lymphadenopathy. Investigations showed:

  • WCC 10.6 x 109/L, Hb 8.4g/dl, Platelets 298 x 109/L
  • CRP 202 mg/L
  • TSH < 0.01, t3- 3.1, t4- 43.0
  • Blood cultures – negative
  • CT scan - thyroid abscess with oesophageal compression but no tracheal compromise.

On the advice of the endocrinologists, prednisone and Luggol’s iodine was started. An ultrasound-guided aspiration of thyroid mass aspirated 18ml of pus from the left lobe followed by incision and drainage. Definitive surgery was not performed due to the risk of thyroid storm. Steroids were stopped after 10 days.

Four days after the I&D, the patient complained of diarrhoea and stool was positive for C. difficile toxin. Treated with metronidazole.

Pus cultured from thyroid aspirate grew N. brasiliensis

Sensitive Resistant
AmikacinAmoxicillin-clavulaenate (MIC 32µg/ml)

Modified Kinyoun stain of thyroid biopsy

The patient developed a right supraclavicular swelling which was incised & drained.

On the basis of his new resistance profile, he stopped amoxicillin-clavulanate and started linezolid 600mg BD.

A CT brain confirmed a poorly enhancing multi-cystic right cerebellar hemisphere mass with surrounding oedema, early hydrocephalus and attenuation of 4th ventricle. Large necrotic submental nodes and multiple necrotic mediastinal and anterior neck nodes were noted on lower cuts.

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