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An Incidental Abscess in a Patient with Acquired Immunodeficiency Syndrome.

CLINICAL CASE A 52-year-old man with acquired immunodeficiency syndrome presented to clinic for routine follow-up. His most recent CD4 count was 69 cells per mm with an undetectable human immunodeficiency virus (HIV) viral load. He had been adherent to antiretrovirals for a number of years but did have a remote history of treated disseminated Mycobacterium avium complex (MAC) infection. He was no longer on MAC prophylactic therapy. He was without complaints and denied any recent symptoms or trauma. His vital signs were within normal limits, and a full physical examination, including musculoskeletal, oropharyngeal, and neurological evaluation, was completely normal except for mild hepatomegaly. A liver protocol computed tomographic (CT) scan was obtained to evaluate the enlarged liver felt on examination. The scan, in Figure 1, revealed a normal liver but noted an incidental 12.0 7.0 4.7-cm left psoas abscess with phlegmonous change around the inferior vena cava and aorta and mild mass effect on the adjacent kidney. Surveillance MAC blood cultures sent 8 weeks before failed to demonstrate growth. White blood cell (WBC) count on presentation was 9900 cells per microliter, with an absolute neutrophil count of 8540 cells per microliter. All other laboratory studies were within the reference range. Peripheral blood cultures revealed no growth of bacterial organisms. The patient had a transthoracic echocardiogram that was negative for endocarditis with high-quality images. The patient underwent CT-guided aspiration of the abscess with drain placement, and the fluid had a WBC count of 315,000 per centimeter squared (89% neutrophils), and Gram and acid-fast stains failed to reveal any organisms. What is the cause of this asymptomatic abscess? FIGURE 1. Coronal plane CT scan of the abdomen and pelvis demonstrating a 12.0 7.0 4.7-cm left psoas muscle abscess (noted by black arrow) in an asymptomatic patient with acquired immunodeficiency syndrome. IMAGES IN ID–WHAT’S THE DIAGNOSIS?