it is very important to distinguish m. abscessus from other nontubercular mycobacteria ( ntm ) as antimycobacterial therapy is significantly more complex . a 53-year - old male patient from gujarat ( india ) , with a history of hypertension , diabetes mellitus , hypothyroidism , and a stable dilated cardiomyopathy was shifted to our hospital with a prolonged pyrexia , which had remained undiagnosed and unresponsive to standard antimicrobial treatment . a coronary angiography had been performed 8 weeks earlier , which showed normal coronary anatomy . three weeks following the angiography , the patient developed moderate- to high - grade fever for which standard investigations , routine blood cultures , and imaging were performed and were inconclusive . he was transferred to our care 6 weeks into his febrile illness with no clear diagnosis . on examination , the patient was febrile , toxic , and had an early diastolic murmur in the aortic area . the investigations revealed hemoglobin 8.3 g / dl , white blood cells 9200 cells / mm , platelets 2,23,000/mm , serum creatinine level 2.2 mg / dl , and erythrocyte sedimentation rate 88 mm / h . urine analysis showed 3 - 5 red blood cells ( rbcs)/high power field ( hpf ) and a raised 24-h urine protein of 1527 mg/24 h was also noted . on ultrasonography , there was mild hepatosplenomegaly , but there was no evidence of focal lesions in the spleen or liver . chest roentgenogram revealed mildly prominent pulmonary vasculature with cardiomegaly but no significant lung parenchymal pathology . the two - dimensional echocardiography ( 2d echo ) done at previous hospital showed left ventricular ejection fraction ( lvef ) of 30% , normal heart valves , and global hypokinesia . a repeat 2d echo at our center showed an evidence of mild aortic regurgitation with three discrete small mobile vegetations on the left and right coronary cusps of the aortic valve . choroidal infiltrates as a stigmata of infective emboli were noted , but there was no evidence of embolization to skin or any other organ . double stranded antibody ( anti - dsdna ) , and anti  nucleophilic cytoplasmic antibodies ( anti - anca ) were negative and complement levels ( c3 and c4 ) were within the normal range . the patient was treated for heart failure and was started on ceftriaxone at a dose of 1 g twice daily intravenously as empirical treatment for infective endocarditis . bactec myco / f lytic medium was then used , which demonstrated the rapidly growing organisms as ntm . linezolid and clarithromycin were empirically added while awaiting the sensitivity and speciation of the ntm . meanwhile , species identification using the line probe assay technique revealed the organism to be m. abscessus and drug sensitivities were subsequently obtained . the organism was found to be sensitive to amikacin , clarithromycin , linezolid , and tobramycin , with intermediate sensitivity to cefoxitin but was found to be resistant to doxycycline , imipenem , cefepime , ceftriaxone , minocycline , and amox  clavulanic acid . the two antibiotics ( linezolid and clarithromycin ) were continued and the other sensitive drugs isoniazid , ethambutol , and cefoxitin were added to the treatment regimen . the patient defervesced for the first time after 7 weeks of continuous fever 1 week into the above treatment . linezolid was withheld for 10 days in view of significant bone marrow suppression but was later reinstituted in lower doses . after 3 weeks of therapy with a combination of five antibiotics , the creatinine stabilized at 2.6 mg / dl having previously reached a peak of 3.6 mg / dl . the valvular vegetations , however , were present and blood cultures still grew the same mycobacteria despite the patient having defervesced . aortic valve replacement surgery was considered but was withheld in view of multiple comorbidities and patient 's reluctance to undergo any procedure . a repeat 2d echo at 4 weeks post treatment showed no change in the vegetation size and the patient was discharged on request on all five antimycobacterial antibiotics . subsequently , the patient developed worsening cardiac failure and died of pulmonary edema and renal dysfunction despite aggressive medical management in a local intensive care unit . postprocedure mycobacterial infections have been often reported , especially in india where glutaraldehyde is used as a sterilizing solution for surgical and other equipments . risk factors for bacteremia following catheterization include obesity , duration of the procedure , the number of balloons used , and the number of skin punctures performed . infections complicating coronary angiography include sepsis , endocarditis , suppurative pancarditis , stent infection , septic arthritis , epidural abscess , necrotizing fasciitis , and groin wound infection . the most common causative organism of bacteremia following cardiac catheterization is staphylococcus aureus , particularly in the obese . native valve endocarditis with ntm such as m. abscessus is rare and often missed without appropriate blood cultures . in cases of postprocedure endocarditis , early diagnosis and prolonged combination therapy are obligatory to minimize mortality , as m. abscessus is inherently resistant to multiple antibiotics . although there are no specific drug protocols for treatment of pulmonary m. abscessus disease , a macrolide - based regimen is often used combined with surgical debridement for successful therapy . evidence - based management for other nonpulmonary diseases and specifically for m. abscessus endocarditis is lacking due to sheer rarity of the condition and treatment is based on in vitro drug susceptibility . typically , antibiotics with maximum in vitro activity against m. abscessus isolates include amikacin , clarithromycin , tigecycline , and cefoxitin . to a lesser extent , combination therapy is mandatory and should be administered for at least 2 - 4 months . tigecycline and linezolid are newer antibiotics with efficacy against m. abscessus and the recommended treatment length with these drugs is 6 - 12 months . among the carbapenems , clarithromycin and linezolid were used in combination as aminoglycosides were contraindicated due to renal failure . the cause of the raised creatinine was thought to be multifactorial , secondary to diabetic nephropathy , hypertension , and congestive cardiac failure . the possibility of septic emboli causing nephritis seems low owing to only 3 - 5 rbcs / hpf in urine . isoniazid and ethambutol were added as standard antituberculous therapy with the hope of some benefit in such a desperate situation . m. abscessus infection is not always considered a medically curable condition , but prolonged antibiotic therapy may result in chronic suppression of the disease . in vitro drug susceptibility patterns do not always correlate with clinical responses and measurements of minimum inhibitory concentrations of antibiotics do not always predict their therapeutic effects . endocarditis caused by m. abscessus generally has a very poor prognosis despite combination antimicrobial therapy , as only two of the 10 documented cases described in the literature have survived after treatment . surgical intervention to replace the infected valve would have been worth attempting if the patient had been willing . however , in view of the dismal treatment outcomes shown by previous studies , it remains uncertain if early institution of appropriate therapy or valve replacement would have altered the ultimately fatal outcome with this pathogen . nosocomial infection control needs to be strengthened particularly at smaller centres where complex interventions are increasingly being conducted .
mycobacterium abscessus is an unusual cause of infection in immunocompetent patients . 
 the intrinsic and acquired resistance of this organism to multiple antibiotics is a major issue in planning treatment regimens . 
 we report a case of m. abscessus endocarditis of the native aortic valve in an immunocompetent patient following coronary angiography with a fatal outcome . 
 the case highlights an unfortunate intervention  related nosocomial infection and the difficulties in chemotherapeutic options for this organism , particularly in the presence of renal failure .