Suppurative Disease Research Articles

Heterozygous cis HYDIN mutations cause primary ciliary dyskinesia.

The product of ciliary gene HYDIN is an integral component for c2b projection within the motile cilia central pair (CP) apparatus. Biallelic mutations of this gene cause primary ciliary dyskinesia (PCD), an uncommon heterogeneous recessive disorder affecting motile cilia, resulting in defective mucociliary clearance that leads to chronic suppurative lung disease. Nasal brushing samples were collected from two siblings attending the Victorian Diagnostic service for PCD. Nasal airway epithelial cells (NAECs) were cultured before cilia structure and function studies using high-speed video microscopy (HSVM), transmission electron microscopy, and immunofluorescence. Cultured NAECs from both siblings showed defective cilia beating patterns under HSVM. A confirmatory PCD diagnosis was achieved through immunofluorescence, which showed the loss of HYDIN and the associated protein SPEF2 from the cilia axoneme. This case report details the diagnosis of two siblings who displayed similar defective cilia beating phenotypes seen in patients with PCD bearing recessive HYDIN mutations. Uniquely, both siblings carry two previously unreported HYDIN mutations, which are in the cis position, demonstrating the possibility for disease manifestation without biallelic mutations of ciliary genes. The authors declare no funding support for this study.

Systemic disseminated nocardiosis in a patient with normal immune function: a case report

Nocardiosis, characterized by poor prognosis and high mortality, is a local or systemic suppurative or granulomatous disease caused by Nocardia that is common in immunosuppressed individuals but rare in populations with normal immune function. This paper described one case of Nocardia gipuzkoensis disseminated infection in a patient with normal immune function by outlining the process of treatment, conducting literature review and by outlining the clinical characteristics, diagnostic criteria and standardized treatments of nocardia disease, in the hope of providing reference for subsequent treatment of rare Nocardia subspecies infections.

Recognizing clinical features of primary ciliary dyskinesia in the perinatal period.

Primary ciliary dyskinesia (PCD) is a rare, motile ciliopathy inherited through mostly autosomal recessive variants that results in chronic ear, sinus, and respiratory disease. Despite neonatal respiratory distress being a common presenting symptom in term infants with PCD, the diagnosis is often delayed due to non-familiarity of neonatal caregivers with phenotypic and diagnostic features of this disease. Organ laterality defects, prenatal cerebral ventriculomegaly, and a family history of suppurative respiratory disease may occur in PCD and should prompt neonatal testing for this condition. In this review of neonatal PCD diagnoses in a large PCD clinic, prevalence and details of neonatal PCD issues are presented, highlighting the typically delayed onset of neonatal respiratory distress and lobar atelectasis on chest radiography, specific presentations in premature neonates, and responses to perinatal therapies.

Prognostic Markers of Acute Suppurative Lung Disease

The mortality rate among patients with acute suppurative lung diseases (ASLD) in the ICU reaches 30%. Early, pathogenetically relevant biomarkers are needed to ensure personification and better efficacy of ASLD treatment. Numeric variations in the counts of immune system cells in patient’s blood can be viewed as such candidate biomarkers.The aim of the study. Identification of potential markers predicting ASLD outcome after community-acquired pneumonia and COVID-19.Materials and methods. The study included 216 in-hospital patients aged 18-87 with ASLD after community-acquired pneumonia with (N=81) and without (N=135) COVID-19 history.Results. Patients survival after COVID-19 was linked to lymphocyte count on Day 1 of hospital stay (hazard ratio, HR=5.9 95%CI 0.9–37.4; P=0.0188, log-rank test). In patients who had not have COVID-19, a difference in survival was associated with lymphocyte (HR=2.9 95%CI 1.0–8.4; P=0.0184, log-rank test; N=135), and monocyte counts (HR=2.7 95% CI 0.8–9.5; P=0.0196, log-rank test) on Day 1 of hospital stay. Patients’ survival after COVID-19 infection depended on SII (systemic immune-inflammation index. HR=9.3 95%CI 1.7–49.8; P=0.0124, log-rank test; N=81, SIRI (systemic inflammatory response index, HR=7.2 95%CI 1.4–36.6; P=0.0339, log-rank test; N=81) and NLR (neutrophil-to-lymphocyte ratio, HR=9.6 95%CI 1.8–52.0; P=0.0108; log-rank test; N=81) values on Day 1 of hospital stay. In patients who did not have COVID-19 SII values had no influence on survival.Conclusion. The lymphocyte count makes it possible to predict outcomes of pleural empyema, regardless of patient’s history of COVID-19, i. e. a decrease in the lymphocyte count below 1.2×10⁹ in 1 L is associated with fatal outcome. Monocyte count carries prognostic information for cases of pleural empyema without previous COVID-19 infection. As for the relative indicators, SIRI, SII and NLR values measured on Day 1 in the hospital were predictors of ASLD outcome only in patients after COVID-19 infection, i. e., higher values were associated with increased risk of death, with NLR index being the most informative. Overall severity of illness above 10 scores by CIRS was associated with an unfavorable ASLD outcome, regardless of patient’s history of COVID-19.

Pulmonary immune profiling reveals common inflammatory endotypes of childhood wheeze and suppurative lung disease

Suppurative lung disease and wheezing are common respiratory diseases of childhood, however due to poor understanding of underlying pathobiology, there are limited treatment options and disease recurrence is common. We aimed to profile the pulmonary and systemic immune response in children with wheeze and CSLD for identification of endotypes that can inform improved clinical management. We used clinical microbiology data, highly multiplexed flow cytometry and immunoassays to compare pulmonary (bronchoalveolar lavage (BAL)) and systemic immunity in children with lung disease and controls. Unsupervised analytical approaches were applied to BAL immune data to explore biological endotypes. We identified two endotypes that were analogous in both frequency and immune signature across both respiratory diseases. The hyper-inflammatory endotype had a 12-fold increase in neutrophil infiltration and upregulation of 14 soluble signatures associated with type 2 inflammation and cell recruitment to tissue. The non-inflammatory endotype was not significantly different to controls. We showed these endotypes are measurable in a clinical setting, and can be defined by measuring only three immune factors in BAL. We identified hyper-inflammatory and non-inflammatory endotypes common across paediatric wheeze and CSLD that, if validated in future studies, has the potential to inform clinical management.

A Clinical-Anatomical-Radiological Study of Extraperitoneal Spaces: A Case Series.

Complications can arise secondary to anorectal suppurative diseases, with infections spreading along the extraperitoneal space, such as the peri-vesical, prevesical, pre-sacral, and pararectal spaces, resulting in abscesses at remote sites, which can make diagnosis more challenging. Due to the absence of peritonitis symptoms, there is a delay in presentation among such patients. Comprehending the intricacies of these areas and the way infection can spread within them is crucial for promptly identifying and effectively draining the extraperitoneal abscess. We present a case series of six patients with a mean age of 45, all males. A total of three patients had undergone incision and drainage after being diagnosed with anorectal suppurative disease and remained symptomatic after the initial surgical intervention of incision and drainage. Two patients initially diagnosed with anterior abdominal abscesses patients, after being treated with incision and drainage, continued to have purulent discharge from the drainage site. Finally, the last patient continued to present with perianal pain after an open hemorrhoidectomy. CTscans of all six patients showed collections in the extraperitoneal spaces correlated with the observed complications. To deepen our understanding of pelvic extraperitoneal spaces, cadaver dissections were conducted and compared with CT images. Through cadaver dissections and CT imaging, the study provides insights into the anatomy and interconnections of pelvic extraperitoneal spaces, emphasizing the importance of early CT scans for diagnosis. Understanding these intricate anatomical structures is essential for accurate diagnosis and efficient and effective treatment. Timely diagnosis is vital to prevent prolonged illness and reduce the risk of complications and mortality. The importance of early CT scans in suspected patients is underscored, which is highly important to expedite appropriate actions.

Management of a Case of Chronic Suppurative Otitis Media with Homoeopathic Medicine Mercurius Solubilis - A Case Report

Introduction: Chronic suppurative otitis media (CSOM) is a long-standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation. In homoeopathy, there are various medicines having a sphere of action on suppurative diseases. This is a show case of Mercurius solubilise Homoeopathic remedy for the case of CSOM: Mercurius solubilise is a black oxide of mercury. It affects the whole system, penetrating every organ and tissue and also has a wonderful effect on suppuration. Mercury, in both acute and subacute forms, is the only drug that effectively prevents suppuration. Case summary: This is the case of 24 yr old man who presented with CSOM and was successfully managed with individualized Homoeopathic medicine, Mercurius Solubilis 200c. The case was followed up with documentation of clinical symptoms and investigation findings. In this article, the ultimate aim is to provide the clinician with a homoeopathic tool in the management of CSOM after having satisfactory results in the case.

Oral and rectal colonization of methicillin-resistant Staphylococcus aureus in long-term care facility residents and their association with clinical status.

Staphylococcus aureus is a commensal bacterium in humans, but it sometimes causes opportunistic infectious diseases such as suppurative skin disease, pneumonia, and enteritis. Therefore, it is important to determine the prevalence of S. aureus and methicillin-resistant S. aureus (MRSA) in individuals, especially older adults. In this study, we investigated the prevalence of S. aureus and MRSA in the oral cavity and feces of residents in long-term care facilities (LTCFs). S. aureus was isolated from the oral cavity of 61/178 (34.3%) participants, including 28 MRSA-positive participants (15.7%), and from the feces of 35/127 (27.6%) participants, including 16 MRSA-positive participants (12.6%). S. aureus and MRSA were isolated from both sites in 19/127 individuals (15.0%) and 10/127 individuals (7.9%), respectively. Among 19 participants with S. aureus isolation from both sites, 17 participants showed the same sequence type (ST) type. Then, we analyzed the correlation of S. aureus and MRSA in the oral cavity and rectum with the participant's condition. S. aureus and MRSA positivity in the oral cavity was significantly related to tube feeding, while there was no correlation of rectal S. aureus/MRSA with any factors. Our findings regarding the oral inhabitation of MRSA and its risk factors indicate the importance of considering countermeasures against MRSA infection in LTCFs.

The Respiratory Microbiome in Paediatric Chronic Wet Cough: What Is Known and Future Directions.

Chronic wet cough for longer than 4 weeks is a hallmark of chronic suppurative lung diseases (CSLD), including protracted bacterial bronchitis (PBB), and bronchiectasis in children. Severe lower respiratory infection early in life is a major risk factor of PBB and paediatric bronchiectasis. In these conditions, failure to clear an underlying endobronchial infection is hypothesised to drive ongoing inflammation and progressive tissue damage that culminates in irreversible bronchiectasis. Historically, the microbiology of paediatric chronic wet cough has been defined by culture-based studies focused on the detection and eradication of specific bacterial pathogens. Various 'omics technologies now allow for a more nuanced investigation of respiratory pathobiology and are enabling development of endotype-based models of care. Recent years have seen substantial advances in defining respiratory endotypes among adults with CSLD; however, less is understood about diseases affecting children. In this review, we explore the current understanding of the airway microbiome among children with chronic wet cough related to the PBB-bronchiectasis diagnostic continuum. We explore concepts emerging from the gut-lung axis and multi-omic studies that are expected to influence PBB and bronchiectasis endotyping efforts. We also consider how our evolving understanding of the airway microbiome is translating to new approaches in chronic wet cough diagnostics and treatments.

Chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand: TSANZ position statement summary.

Chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand: TSANZ position statement summary.

Caseous lymphadenitis: A case of sheep and its management in Ethiopia

Caseous lymphadenitis (CLA) is a contagious and chronic bacterial disease of animals that affects the lymphatic system with the formation of abscesses. This case report documents a sheep diagnosed with CLA that was brought to the Veterinary Teaching Hospital of Addis Ababa University College of Veterinary Medicine and Agriculture (AAU-CVMA), Bishoftu on March 06/2022. The primary complaint was weakness, anorexia, and a slight, fluctuating, sickleshaped, enlarged swelling in the neck region between the ear and jaws, which developed due to a laceration by a wire on the fence. Physical and clinical examination revealed increased body temperature (40.7oC) and respiratory rate (44 breaths/min) and mildly fluctuating swelling on lymph nodes. Anorexia, coughing, general ill thrift, exercise intolerance, and enlargement of subcutaneous tissues and lymph nodes around the neck region were observed. Aspiration of the swelling revealed thick, pale greenish-cheesy pus. Using the Ethiopian Differential Diagnosis and Information Environment App-based diagnosis and bacterial culture of the pus revealed the case as CLA. It was managed by surgical removal of the pus, topical wound spray, and systemic administration of fortified procaine penicillin for five days intramuscular and once topically on the site, respectively. The sheep recovered after a month. In conclusion, CLA is a challenging suppurative disease of sheep and goats that can be successfully treated by topical wound management and systemic penicillin therapy.

Computed tomography of suppurative and neoplastic diseases involving the canine omenta and omental bursa.

The greater and lesser omenta are fused peritoneal folds that largely delimit the omental bursa (lesser peritoneal cavity). The omental bursa is a potential space within the abdominal cavity that communicates with the greater peritoneal cavity via the omental (epiploic) foramen: it is subdivided into the omental vestibule, caudal omental recess, and splenic recess. Aims of this retrospective case series study were to describe the frequencies of CT findings of dogs with confirmed inflammatory or neoplastic disease of the omenta, omental bursa, or both. The sample included seven adult, medium-to-large breed dogs. All had fluid in the greater peritoneal cavity and 5/7 (71%) dogs also had fluid in the omental bursa. Primary suppurative inflammatory disease was present in three dogs, each dog had a large abscess with central gas in either the omental vestibule (two dogs) or caudal omental recess (one dog). Both abscesses in the omental vestibule arose from the papillary process of the caudate liver lobe and were surgically removed without complication. Neoplasia was present in four dogs and either arose from omentum (hemangiosarcoma, carcinoma) or infiltrated the omentum from an adjacent organ (splenic leiomyosarcoma, gastric adenocarcinoma). Neoplasms created mass-like tumors, infiltrative tumors, or both and had variable distribution (focal, multifocal, or locally extensive). All dogs with neoplasia were euthanized. CT signs of inflammatory and neoplastic disease overlapped, but the presence of gas might prioritize abscessation. CT signs helped decide feasibility of surgery based on extent of local invasion, especially involvement of structures passing through the porta hepatis.

Graves’ Disease and Subdural Empyema Due to Pansinusitis: Case Report

Background: Graves' disease is an autoimmune disease that primarily affects the thyroid gland. It may also affect multiple other organs including eyes and skin. Brain abscess and subdural empyema are serious infections that can stem from chronic suppurative diseases, congenital cardiomyopathy, consequences of head injury, or neurosurgical intervention, but the most frequently from chronic sinusitis or otitis. Case Presentation: A woman, age 22 years old, unmarried, came to the hospital with the main complaint of persistent headaches. Headache since 2 weeks ago along with fever that disappears arises without seizures. There is a lump in the neck for 3 years, and it has grown larger measuring 1x3 cm, immobile and supple. Nausea, vomiting, and decreased appetite are found. Thyroid fungtion test FT4 7.52 (0.93-1.7) ng/dL and TSH 0.01 (0.270-4.20) mIU/L. Chest X-ray: Dextrocardia and Cardiomegaly; MSCT Scan Head/Brain: conclusion: Pansinusitis and Right &; Left Mastoiditis; Ultrasound: thyroid: bilateral diffuse struma. MRI of the BRAIN with IV contrast: illustrating the subdural empyema. Treatment: Meropenem injection 2 g/24 hours, Dexamethasone injection 5mg/8 hours, Amitriptyline 2x12.5 mg, Thiamazole 1 x 20 mg, Propranolol 2 x 10 mg, PCT 3x1000 mg with pain scale monitoring. Conclusion: After being treated at the hospital for 8 days, complaints of headache began to decrease, and if the general condition was stable, the patient would be planned for a craniotomy with evacuation of an abscess in the brain.

Associated Risk Factors and Diagnostic Value of Fiberoptic Bronchoscopy for Protracted Bacterial Bronchitis in Children.

Untreated protracted bacterial bronchitis (PBB), a chronic wet cough prevalent in children, may lead to chronic suppurative lung disease. However, clinical diagnostic criteria are currently nonspecific; thus, PBB may be misdiagnosed. Thus, we assessed the diagnostic value of fiberoptic bronchoscopy (FOB) and the risk factors associated with PBB. Children with chronic cough at The First Affiliated Hospital of Anhui Medical University from January 2015 to May 2020 were enrolled and allocated to a suspected PBB (n = 141) or a non-PBB (n = 206) group. All children underwent extensive laboratory, chest imaging, and allergen tests. Children with suspected PBB underwent FOB with bronchoalveolar lavage; lavage and sputum samples were cultured. All 347 children had a chronic wet cough for approximately 2 months. Of 141 children with suspected PBB, 140 received FOB with bronchoalveolar lavage. Visible tracheal changes included pale mucosa, mucosal congestion, edema, swelling, and increased secretions attached to the wall. Sputum was visible primarily in the left main bronchus (78.7%), left lower lobe (59.6%), right upper lobe (62.4%), and right lower lobe (64.5%). Sputum properties and amounts significantly differed between children with vs. without PBB (P < 0.05). Dermatophagoides (odds ratio (OR), 2.642; 95% CI, 1.283-5.369), milk protein (OR, 2.452; 95% CI, 1.243-4.836) allergies, and eczema (OR, 1.763; 95% CI, 1.011-3.075) were risk factors significantly associated with PBB. Dermatophagoides, milk protein, and eczema were associated with an increased risk of PBB. Sputum distribution and tracheal wall changes observed through FOB may distinguish PBB and assist in its diagnosis.

Diagnostic value of nasal nitric oxide for children with primary ciliary dyskinesia

Objective: To evaluate the value of nasal nitric oxide (nNO) measurement as a diagnostic tool for Chinese patients with primary ciliary dyskinesia (PCD). Methods: This study is a retrospective study. The patients were recruited from those who were admitted to the respiratory Department of Respiratory Medicine, Children's Hospital of Fudan University from March 2018 to September 2022. Children with PCD were included as the PCD group, and children with situs inversus or ambiguus, cystic fibrosis (CF), bronchiectasis, chronic suppurative lung disease and asthma were included as the PCD symptom-similar group. Children who visited the Department of Child health Care and urology in the same hospital from December 2022 to January 2023 were selected as nNO normal control group. nNO was measured during plateau exhalation against resistance in three groups. Mann-Whitney U test was used to analyze the nNO data. The receiver operating characteristic of nNO value for the diagnosis of PCD was plotted and, the area under the curve and Youden index was calculated to find the best cut-off value. Results: nNO was measured in 40 patients with PCD group, 75 PCD symptom-similar group (including 23 cases of situs inversus or ambiguus, 8 cases of CF, 26 cases of bronchiectasis or chronic suppurative lung disease, 18 cases of asthma), and 55 nNO normal controls group. The age of the three groups was respectively 9.7 (6.7,13.4), 9.3 (7.0,13.0) and 9.9 (7.3,13.0) years old. nNO values were significantly lower in children with PCD than in PCD symptom-similar group and nNO normal controls (12 (9,19) vs. 182 (121,222), 209 (165,261) nl/min, U=143.00, 2.00, both P<0.001). In the PCD symptom-similar group, situs inversus or ambiguus, CF, bronchiectasis or chronic suppurative lung disease and asthma were significantly higher than children with PCD (185 (123,218), 97 (52, 132), 154 (31, 202), 266 (202,414) vs. 12 (9,19) nl/min,U=1.00, 9.00, 133.00, 0, all P<0.001). A cut-off value of 84 nl/min could provide the best sensitivity (0.98) and specificity (0.92) with an area under the curve of 0.97 (95%CI 0.95-1.00, P<0.001). Conclusions: nNO value can draw a distinction between patients with PCD and others. A cut-off value of 84 nl/min is recommended for children with PCD.

Chronic Suppurative Lung Disease in Children: A Case Based Approach.

Bronchiectasis is a pathologic state of conducting airways manifested radiographically by evidence of bronchial dilation and clinically by chronic productive cough. Considered an "orphan disease" for long, it remains a major contributor to morbidity and mortality in both developed and underdeveloped countries. With the advances in the medical field accompanied by widespread access to vaccines and antibiotics, improved health services and better access to nutrition, the incidences of bronchiectasis have markedly decreased, particularly in developed countries. This review summarizes the current knowledge pertaining to the clinical definition, etiology, clinical approach and management related to pediatric bronchiectasis.

An Automated Broncho-Arterial (BA) Pair Segmentation Process and Assessment of BA Ratios in Children with Bronchiectasis Using Lung HRCT Scans: A Pilot Study.

Bronchiectasis in children can progress to a severe lung condition if not diagnosed and treated early. The radiological diagnostic criteria for the diagnosis of bronchiectasis is an increased broncho-arterial (BA) ratio. From high-resolution computed tomography (HRCT) scans, the BA pairs must be detected first to derive the BA ratio. This study aims to identify potential BA pairs from HRCT scans of children undertaken to evaluate suppurative lung disease through an automated approach. After segmenting the lung regions, the HRCT scans are cleaned using a histogram analysis-based approach followed by a potential arteries identification process comprising four conditions based on imaging features. Potential arteries and their connected components are extracted, and potential bronchi are identified. Finally, the coordinates of potential arteries and potential bronchi are matched as the last step of BA pairs extraction. A total of 8-50 BA pairs are detected for each patient. Additionally, the area and several diameters of the bronchi and arteries are measured, and BA ratios based on these are calculated. Through this approach, the BA pairs of a CT scan datasets are detected and utilizing a deep learning model, a high classification test accuracy of 98.53% is achieved, validating the robustness of the proposed BA detection approach. The results show that visible BA pairs can be identified and segmented automatically, and the BA ratio calculated may help diagnose bronchiectasis with less effort and time.

Pathogenesis of nontypeable Haemophilus influenzae infections in chronic suppurative lung disease.

The respiratory tract antimicrobial defense system is a multilayered defense mechanism that relies upon mucociliary clearance and components of both the innate and adaptive immune systems to protect the lungs from inhaled or aspirated microorganisms. One of these potential pathogens, nontypeable Haemophilus influenzae (NTHi), adopts several, multifaceted redundant strategies to successfully colonize the lower airways and establish a persistent infection. NTHi can impair mucociliary clearance, express multiple multifunctional adhesins for various cell types within the respiratory tract and evade host defenses by surviving within and between cells, forming biofilms, increasing antigenic drift, secreting proteases and antioxidants, and by host-pathogen cross-talk, impair macrophage and neutrophil function. NTHi is recognized as an important pathogen in several chronic lower respiratory disorders, such as protracted bacterial bronchitis, bronchiectasis, cystic fibrosis, and primary ciliary dyskinesia. The persistence of NTHi in human airways, including its capacity to form biofilms, results in chronic infection and inflammation, which can ultimately injure airway wall structures. The complex nature of the molecular pathogenetic mechanisms employed by NTHi is incompletely understood but improved understanding of its pathobiology will be important for developing effective therapies and vaccines, especially given the marked genetic heterogeneity of NTHi and its possession of phase-variable genes. Currently, no vaccine candidates are ready for large phase III clinical trials.

Personalising airway clearance in chronic suppurative lung diseases: a scoping review.

Personalised airway clearance techniques are commonly recommended to augment mucus clearance in chronic suppurative lung diseases. It is unclear what current literature tells us about how airway clearance regimens should be personalised. This scoping review explores current research on airway clearance technique in chronic suppurative lung diseases, to establish the extent and type of guidance in this area, identify knowledge gaps and determine the factors which physiotherapists should consider when personalising airway clearance regimens. Systematic searching of online databases (MEDLINE, EMBASE, CINAHL, PEDro, Cochrane, Web of Science) was used to identify full-text publications in the last 25 years that described methods of personalising airway clearance techniques in chronic suppurative lung diseases. Items from the TIDieR framework provided a priori categories which were modified based on the initial data to develop a "Best-fit" framework for data charting. The findings were subsequently transformed into a personalisation model. A broad range of publications were identified, most commonly general review papers (44%). The items identified were grouped into seven personalisation factors: physical, psychosocial, airway clearance technique (ACT) type, procedures, dosage, response and provider. As only two divergent models of ACT personalisation were found, the personalisation factors identified were then used to develop a model for physiotherapists. The personalisation of airway clearance regimens is widely discussed in the current literature, which provides a range of factors that should be considered. This review summarises the current literature, organising findings into a proposed airway clearance personalisation model, to provide clarity in this field.

P028 Oh No-Cardiosis! A case of systemic Nocardia nova infection

Abstract Background/Aims Nocardiosis is a rare infectious disease caused by the aerobic bacteria genus Nocardia and can cause severe suppurative disease affecting virtually any organ. It tends to affect the immunocompromised, making rheumatology patients a particular risk group for this infection. It is not normal human flora and is found in soil, decaying vegetable matter and aquatic environments. It can become airborne and the most common means of entry is thought to be dust inhalation. Methods Our patient is a 75-year-old woman with giant cell arteritis (GCA) treated with prednisolone, SC methotrexate and tocilizumab (started 4 months before her acute illness). Symptoms began with a fall in the garden sustaining a nasty laceration to her leg and an injury to her back worsening some chronic lower back pain (X-rays did not show any fracture). Over the next 5 weeks due to a productive cough and sweats she was prescribed oral antibiotics with no improvement. She was then admitted to hospital due to an acute increase in the severity of her lower back pain alongside a change in character to a burning pain. Her presenting CRP was 32, likely due to having held tocilizumab due to a presumed chest infection. MRI showed a collection in the right erector spinae muscle extending from C7 to the iliac crest and another large collection in the right thigh. A mass in the left sub-mammary area led to a chest CT that showed a chest wall abscess alongside a spiculated lesion in the lung, and further nodular changes. Peripheral blood cultures were negative and eventually draining of the erector spinae abscess led to culture of Nocardiosis nova. Imipenam and Septrin were given as per sensitivities. Unfortunately, our patient has had a difficult clinical course. During her hospital stay she has had possible DRESS syndrome/Septrin-induced liver injury alongside drug induced neutropaenia and lymphopaenia and a possible stroke (this was thought less likely to represent CNS Nocardiosis). Results Her rheumatology management initially involved stopping her DMARDs however due to flares in symptoms her doses of prednisolone have been up and down. It has been difficult to separate symptoms that may be due to cervical spine collections and a possible CNS lesion from GCA symptoms. Conclusion This case demonstrates the need to thoroughly investigate immunosuppressed patients when they are not responding as expected to antibiotics or present with atypical symptoms. It also demonstrates the importance of obtaining a microbiological diagnosis. Cellular immunity is generally thought to be key in preventing Nocardia dissemination however in our patient’s case she was only taking 2.5mg prednisolone when admitted. This is one of only a few case reports of patients developing Nocardia infection whilst on tocilizumab. Disclosure R.J. Crowder: None. H. Mills: None. O. Savanovic-Abel: None. J. King: None. O. Moore: None. M. Perry: None. S. Hewagamage: None. M. Gunathilaka: None.