A 37-year-old african-american male was referred to the endocrinology department of the Federal Hospital of Lagoa for evaluation of adrenal insufficiency due to chronic and irregular use of steroids (Prednisone 20 to 40 mg/day) for 10 years. He had history of use of anabolic drugs and intramuscular mineral oil (hydrogel) injections in the upper and lower limbs for 15 years for muscle hypertrophy. Three months prior to the referral he developed intense headache, fever, night sweats, weight loss and limb pain. No other systemic comorbidities.
During hospitalization, intramuscular purulent collections were diagnosed by imaging tests and he presented daily fever (maximum of 38  C or 100  F). Treatment with piperacillin/tazobactam 2.25 g IV q6hr and vancomycin 500 mg IV q6hr was initiated and laboratory tests collected. The blood tests showed 11,900 leukocytes (90% neutrophils), high level of C reactive protein, negative blood culture, culture of the intramuscular purulent material negative, negative serology for HIV and syphilis. Chest and cranial computed tomography scans were normal. The cerebrospinal fluid showed the presence of 330 cells (60% mononuclear), 239 mg/dL proteins, 49 mg/dL glucose, negative Nanquin test, negative latex fixation test, negative bacterioscopy, negative cytomegalovirus serology. The polymerase chain reaction (PCR) result for Koch's bacillus was in process at this time. Drainage of right thigh abscess was performed and material sent to culture.
Ophthalmology Service was then requested for evaluation. Visual acuity was 20/20 in both eyes, anterior biomicroscopy and intra-ocular pressure were normal. Fundus examination revealed subretinal, elevated, rounded, yellowish lesions in the nasal region in the right eye and superior to the macula in the left eye (Fig. 1). 
On fluorescein angiography (FA), these lesions showed punctate leakage (Fig. 2). The optical coherence tomography (OCT) revealed choroidal lesions causing elevation of the retinal pigment epithelium (RPE) and subretinal fluid (Fig. 3).  
Considering systemic symptoms, suggestive laboratory and retinal lesions, the hypothesis of systemic tuberculosis with choroidal granuloma was assumed. After 14 days of treatment with piperacillin/tazobactam and vancomycin without clinical or laboratory response, the therapy was switched to rifampicin, isoniazid, pyrazinamide and ethambutol. At this point, several cultures of the material drained from the abscess were negative.
After 4 weeks of treatment for tuberculosis, the patient maintained the symptoms and no improvement of laboratory tests. The possibility of fast growing atypical mycobacteria was considered and the empirical treatment for mycobacteria with amikacin and clarithromycin was added to previous tuberculosis treatment.
Posteriorly to the change on the treatment, the patient presented clinical improvement and leukocytes progressively reduced from 16,500 to 7800 after 2 days. Then, one of the cultures collected from the left thigh confirmed the growth of non-tuberculous mycobacteria and the agent Mycobacterium Fortuitum was isolated. It was susceptible to the following antibiotics: amikacin, ciprofloxacin, doxycycline and moxifloxacin. At this time, the antibiotic therapy was replaced by doxycycline 200 mg/day and ciprofloxacin 1 g/day, oral administration.
After 6 months of targeted treatment, the fundus exam revealed a significant regression of the lesions (Fig. 4). The FA still showed discrete leakage (Fig. 5) and the OCT demonstrated regression of the choroidal lesion and subretinal fluid, which were replaced by areas of retinal atrophy (Fig. 6).