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Tissue biopsy showed typical staphylococcal granular colonies. Treatment To optimise the antibiotic coverage a medicine consultation was sought and the patient was started on injection piperacillin�Ctazobactum in a dose of 4.5?g 8 hourly to which the patient developed nausea, vomiting, diarrhoea and gastrointestinal intolerance. Hence the drug had to be stopped. The patient was then started on injection vancomycin 1?g intravenously twice daily for 2?weeks, followed by tab linezolid 600?mg twice daily for 6?weeks with monitoring of serum electrolytes, blood urea and serum creatine, along with anticonvulsants to which the patient responded well. Topically he was put on clindamycin skin ointment over the sinuses three times daily for 6?weeks along tear supplements and tobramycin eye ointment to the right eye. Outcome and follow-up The patient showed remarkable improvement with reduction in the size of the swelling and proptosis (figure 4A,B). Figure?4 (A) Showing resolution of the skin lesions with significant reduction in proptosis and chemosis with exposure keratopathy. (B) Lateral view showing significant reduction in proptosis, healed skin buy Vemurafenib nodules and sinuses with exposure keratopathy. Discussion Winslow subcategorised botryomycosis into integumental and visceral forms. The integumental form is more common and is characterised by localised granulomatous skin infections often associated with trauma, foreign body and wound contamination. Visceral form affecting the liver, lung, kidney, prostate, caecum, brain, lymph tissue and orbit is rare.3 Our 53-year-old patient following trauma presented with proptosis (a primary orbital lesion) with intracranial involvement, involvement of the fronto temporal area and paranasal sinuses. Considering the diagnosis of granulomas such as actinomycosis and mycetoma biopsy from the discharging sinuses overlying the skin and periorbital tissue was carried out. Histopathological examination and biopsy of the specimen revealed a chronic granulomatous reaction to deep bacterial infection caused by Staphylococcus aureus. Although extensive surgical debridement with systemic antibiotics is the treatment of choice4 in view of the significant intracranial extension, decision was taken to try medical line of management. Patient responded to intensive antibiotic therapy with vancomycin for 2?weeks and linezolid for 6?weeks along with 6?weeks of topical clindamycin therapy. It is quoted that the mortality is high in case of intracranial extension.5 In this case on presentation there was extensive intracranial involvement causing midline shift. Despite this the patient responded very well to medical management.