A primary hepatic gastrointestinal stromal tumor presenting with fever, initially misdiagnosed as liver abscess and drained was ultimately confirmed by pathology.

Wiskott-aldrich syndrome (WAS) is a rare X-linked primary immunodeficiency characterized by thrombocytopenia, eczema, and recurrent infections. Live vaccines, such as Bacillus Calmette-Guérin (BCG), routinely administered in tuberculosis-endemic regions, may cause severe complications in undiagnosed patients. We report a 2-year-old boy with genetically confirmed WAS who developed a rare BCG-related brain abscess. The patient initially presented with neonatal thrombocytopenia and eczema, followed by recurrent respiratory and gastrointestinal infections. Whole exome sequencing identified a pathogenic mutation in the WAS gene. During pre-hematopoietic stem cell transplantation (HSCT) evaluation, brain imaging revealed a large multiloculated right parieto-occipital abscess with significant mass effect. Surgical drainage was performed, and polymerase chain reaction confirmed Mycobacterium bovis (BCG strain). Antitubercular therapy was initiated. Severe thrombocytopenia complicated management and necessitated splenectomy. Although platelet counts improved and infection was partially controlled, HSCT was postponed due to active infection. The patient subsequently died following a severe COVID-19 infection. This case highlights the diagnostic and therapeutic challenges of BCG-related brain abscess in patients with WAS and underscores the importance of early genetic diagnosis, avoidance of live vaccines, and timely definitive treatment in primary immunodeficiencies.

We present a case of disseminated Nocardia otitidiscaviarum infection in a 72-year-old male with a history of renal transplantation on chronic immunosuppressive therapy with prednisone, cyclosporine, and mycophenolate mofetil. He presented with pneumonia and was initially treated with ceftriaxone and azithromycin. Bronchoalveolar lavage (BAL) and cultures from a biopsied thigh lesion both grew N. otitidiscaviarum. His hospital course was complicated by visual hallucinations, and brain magnetic resonance imaging (MRI) revealed multiple intracranial abscesses. He initially received meropenem, trimethoprim-sulfamethoxazole (TMP-SMX), and linezolid. His antimicrobial regimen was subsequently modified during the treatment course. Linezolid was discontinued after hematologic abnormalities developed, TMP-SMX was temporarily held because of worsening renal function and later reintroduced, and meropenem was also discontinued. He was discharged on TMP-SMX and minocycline and completed an initial six-week antimicrobial treatment course from the time of diagnosis. He was subsequently maintained on minocycline and moxifloxacin; moxifloxacin was later discontinued because of QT-interval prolongation, while minocycline was continued for slightly longer than one year, with clinical and radiologic resolution.

Bartonella infective endocarditis (IE) is a rare cause of initially blood culture-negative IE, classically associated with cat flea exposure in Bartonella henselae infection or body lice infestation among individuals experiencing homelessness or alcoholism in Bartonella quintana infection. We report the case of an 84-year-old man with severe calcific aortic stenosis who was undergoing evaluation for pre-transcatheter aortic valve implantation (TAVI). Cardiac computed tomography (CT) unexpectedly revealed a peri-annular cavity consistent with a drained or healed peri-annular abscess, despite the absence of fever or other clinical features of IE. Initial blood cultures were negative, and TAVI was planned following multidisciplinary discussion, pending serological results. However, a subsequently reported high-titer Bartonella serology prompted readmission, and TAVI was ultimately deferred after the diagnosis was confirmed. Prolonged incubation of blood cultures subsequently identified B. quintana, while brain magnetic resonance imaging (MRI) revealed a lesion suspicious for an intracranial infectious aneurysm. Definite IE was established according to the 2023 Duke-International Society for Cardiovascular Infectious Diseases (Duke-ISCVID) criteria based on two major criteria: high-titer Bartonella serology and imaging evidence of a peri-annular abscess. No classical epidemiological risk factors for Bartonella infection were identified. Despite targeted antimicrobial therapy, the patient experienced progressive clinical deterioration, and multiple comorbidities precluded surgical intervention. He ultimately died of multiorgan failure. This case highlights the diagnostic challenge of occult B. quintana IE incidentally identified during pre-TAVI evaluation, including in patients without classical epidemiological risk factors or overt manifestations of infection. It also emphasizes that unexpected peri-annular abnormalities detected during pre-TAVI evaluation should prompt a thorough investigation for IE, even in clinically unsuspected cases, with direct implications for procedural planning.

Cerebral abscesses can mimic brain tumors or metastases on imaging, posing a significant diagnostic challenge, especially in patients without obvious infectious sources. We report the case of a 46-year-old woman with a history of spinal cord lesion biopsy, who presented with a three-week history of headaches and vomiting, progressing to dysarthria, right-sided hemiplegia, and consciousness impairment over 24 hours. On admission, she was unconscious (Glasgow Coma Scale (GCS) 7/15), with left anisocoria, requiring intubation and mechanical ventilation. Brain CT revealed intra-axial lesions suggestive of cerebral metastases. Emergency surgery was performed on the largest left frontoparietal lesion. Intraoperatively, the lesion contained purulent material, which was sterile on microbiological culture. No preoperative antibiotics had been administered. Histopathology confirmed the presence of purulent material, consistent with a cerebral abscess. Postoperatively, the patient received triple antibiotic therapy, corticosteroids, and intensive supportive care. Despite maximal treatment, there was no neurological improvement, and the patient subsequently died. This case highlights the difficulty in differentiating cerebral abscesses from metastatic brain tumors in the absence of a clear infectious source. Early consideration of abscess in the differential diagnosis and prompt surgical intervention remain critical, although outcomes may be poor in rapidly progressing cases.

Spinal subdural abscess is an exceptionally rare and potentially life-threatening spinal infection characterized by the accumulation of purulent material between the dura and arachnoid mater. In contrast to the more common spinal epidural abscess, spinal subdural abscesses have been reported in fewer than 80 cases, often in pediatric, postoperative, or immunocompromised patients. This case represents the fourth documented instance of a spinal subdural abscess in an immunocompetent adult without identifiable risk factors or a known source of infection and the first reported in emergency medicine literature. A 60-year-old immunocompetent woman presented to the emergency department with atraumatic low back pain initially attributed to lumbar radiculopathy. She returned six days later with worsening bilateral radicular pain, urinary incontinence, and systemic symptoms. Magnetic resonance imaging (MRI) revealed a large subdural fluid collection from T2 to L5, concerning for spinal subdural abscess. Emergent surgical decompression revealed frank purulence within the subdural space. Cultures grew Streptococcus intermedius, a rare pathogen in spinal infections. The patient completed an 8-week course of intravenous cefazolin and recovered fully with resolution of neurologic deficits. Spinal subdural abscesses can progress rapidly, causing widespread neurologic impairment due to the continuity of the subdural space. This case underscores the importance of maintaining a high index of suspicion for spinal infections in patients presenting with back pain and neurological deficits, even in immunocompetent patients. Early MRI and surgical consultation are essential to prevent irreversible neurological damage and optimize patient outcomes.

Amyand's hernia is defined as the presence of the vermiform appendix within an inguinal hernia and becomes particularly challenging when appendicitis progresses to perforation and extra-abdominal sepsis. We report a 60-year-old man with one week of progressive abdominal pain, reduced appetite, constipation, and impaired ambulation followed by three days of painful right inguinoscrotal enlargement. Examination showed an irreducible, inflamed right inguinoscrotal mass. Laboratory testing demonstrated leukocytes of 19.35 × 10[3]/µL, neutrophils of 92%, and bands of 13%. Ultrasonography showed a right inguinal wall defect with non-reducing omentum and bowel and complex scrotal contents. Emergency inguinal exploration drained approximately 400 mL of frank purulent material and demonstrated severe ischemic changes of the right spermatic cord and testis. Given the extent of the operative findings, midline laparotomy was performed; a retroperitoneal abscess communicating with the inguinal region and a gangrenous perforated appendix were identified, with the perforation approximately 1.5 cm from the appendiceal base. Appendectomy, retroperitoneal and scrotal drainage, Penrose drain placement, right orchiectomy for nonviability, and Shouldice tissue repair without mesh were performed. Recovery was favorable without known immediate complications. This case illustrates a severe Type III Amyand's hernia with simultaneous retroperitoneal and inguinoscrotal septic extension and irreversible testicular ischemia. In grossly contaminated presentations, prompt source control, excision of nonviable tissue, and nonprosthetic hernia repair remain pragmatic priorities.

A boy in late adolescence presented with fever, weight loss, mediastinal and retroperitoneal lymphadenopathy, and was diagnosed with extrapulmonary tuberculosis. His clinical course was complicated by drug-induced liver injury, a tubercular psoas abscess requiring percutaneous drainage. After this procedure he developed rapidly recurring chylous ascites requiring frequent large-volume paracentesis. Despite prolonged antitubercular therapy, ascites persisted. Magnetic resonance lymphangiography demonstrated leakage from retroperitoneal lymphatics into the right perinephric region together with non-opacification of the thoracic duct beyond the cisterna chyli, suggesting lymphatic obstruction secondary to healed tuberculous lymphadenitis. Conservative measures, including dietary modification and octreotide, were unsuccessful. The patient underwent intranodal lymphatic embolisation using a glue-lipiodol mixture, resulting in sustained resolution of ascites. This case highlights the complex lymphatic complications of tuberculosis and demonstrates the diagnostic and therapeutic value of advanced lymphatic imaging and embolisation in refractory chylous ascites.