A forty-two-year-old female PLHIV (people living with HIV) not on antiretroviral treatment (ART) was admitted with the history of sudden onset left hemiplegia and altered sensorium for 4 days. There was no history of fever, headache, vomiting or convulsion. She received antituberculosis treatment for pulmonary tuberculosis 6 months back. On examination she was afebrile, pulse was 54 per minute regular and blood pressure was 140/90 mmHg. Pallor and oral candidiasis were noted. There was no evidence of lymphadenopathy.
Central nervous system examination revealed GCS of 5/15. Right pupil was dilated and nonreacting, no papilledema on fundoscopy. Left upper motor neuron facial palsy present. Patient had left hemiplegia. Other systems examination was normal.
On investigations, her hemoglobin was 9 gm%, total leucocytic count was 8000/cumm. Metabolic lab was normal. Her CD4 count was 14/cumm and chest X-ray was normal. CT scan brain showed large 5x4x4.5 cm abscess in right frontoparietal region with severe mass effect and leptomeningitis. [Figure 1]. Urgent drainage of intracranial abscess was done by neurosurgeon. Approximately 50 cc pus was drained.
Patient became ambulatory by fifth postoperative day with marked improvement in sensorium.
Acid fast bacilli were seen on ZN staining of pus. Pus was inoculated on Lowenstein Jensen's medium. Single white colony was grown by second week which was not rough and dry as seen in typical myocobacterium tuberculosis growth, but was smooth and wet in appearance and nonpigmented. Smear was strongly positive for acid-fast bacilli which were long and slender. Further confirmation was done by niacin test which was negative which favored the infection by NTM. The organism was further identified as MAI by standard biochemical tests.
Patient was started on tab Clarithromycin, tab Ethambutol, and ART. Repeat CT scan brain after 1 week, showed reduction in the size of abscess with perilesional edema [Figure 1].