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  1. Jonathan Witherick,
  2. Begoña Bovill,
  3. Anni Dong,
  4. Mahableshwar Albur,
  5. Rose Bosnell
  1. Southmead Hospital, Bristol


Background Multiple ring-enhancing brain lesions have a wide differential. We report a case with a rare cause that was successfully treated.

Case report An 18 year old presented with a short history of headache, dry cough and fevers. His past medical history included Aspergers, childhood epilepsy and bilateral hearing loss (with identified chromosomal translocation) and a recent diagnosis of trans-bronchial biopsy-positive sarcoidosis for which he was taking prednisolone. Radiology showed left upper zone consolidation; despite initial improvement with piperacillin-tazobactam, his headaches intensified and contrast-enhanced brain imaging demonstrated multiple ring-enhancing lesions; lesions were also identified in the liver and spleen. CSF analysis confirmed active inflammation but cultures (including liver biopsy) were negative. Subsequently liver tissue 16S rDNA rtPCR analysis identified rDNA of the pseudomonas genus with a 99% sequence homology for P.luteola and P.zeshuii. These soil-dwelling organisms may have been acquired by the patient whilst working on his grandfather's allotment. The patient was successfully treated with Meropenem.

Conclusion This case involved input from multiple clinical specialties and highlights the collaboration needed to diagnose and manage such a rare organism. The case highlights unusual pathogens that may cause opportunistic infection in the immunocompromised host and the importance of a thorough occupational history.

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