MON-343 Nocardia Farcinia Adrenal Abscess Mimicking Adrenal Adenoma

Background: Infection by Nocardia in immunocompetent individuals is uncommon. Isolated adrenal involvement by Nocardia is rare. We report a case of unilateral Nocardia adrenal abscess that presented as lesion mimicking adrenal adenoma which resulted in dissemination in an immunocompetent host. Case Presentation: A 67 years old male with past medical history of coronary artery disease presented to his physician’s office with 5/10 pain in the left flank area for two weeks that radiated into the left upper quadrant. He had weight loss more than 10 pounds in one month, anorexia and night sweats. On examination, he was hemodynamically stable and there was no abdominal tenderness. Routine blood work and a computed tomography [CT] scan of abdomen was obtained that showed a heterogeneously enhancing 8.1 cm x 4 cm x 5 cm partially necrotic left adrenal mass [Figure 1]. Lab work revealed that serum aldosterone, serum renin, plasma metanephrine and urine free cortisol were in normal range. In a few days, patient presented with acute episode of hypotension to the Emergency department. A CT scan of abdomen was that revealed he had large retroperitoneal fluid collection. He received intravenous fluid resuscitation and was started on empiric treatment with Vancomycin and Piperacillin-tazobactam for concern of sepsis. He underwent surgical exploration, incision and drainage of left retroperitoneal abscess collection with removal of two liters of purulent fluid [Figure 2]. Initial gram stain had shown filamentous, acid fast bacteria. He was started on treatment empirically with Amikacin, Trimethoprim–sulfamethoxazole [TMP–SMX] and Imipenem- Cilastatin. The patient was found to have disseminated nocardiosis with positive blood cultures and abdominal abscess growing Nocardia farcinica. Antibiotics were tapered to Imipenem- Cilastatin, Amikacin and Moxifloxacin to complete six weeks of antibiotic therapy. CT scans of chest and head were obtained which did not reveal any signs of abscess. Patient recovered well with repeat imaging studies showing resolution of the abscess. Conclusion: Nocardia involvement of adrenal gland is a rare phenomenon, it can present as solitary adrenal lesion or with dissemination. This can mimic adrenal adenoma on CT scan. On review of existing medical research, less than ten cases of isolated Nocardia adrenal abscess leading to dissemination has been described so far. Isolated involvement of the adrenal gland poses diagnostic challenge because of non-localizing symptoms and late presentation with dissemination. Figure 1 Partially necrotic left adrenal massFigure 2 Retroperitoneal abscess