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Lack of drug effect: case report A 7-month-old boy exhibited lack of drug effect during treatment with clindamycin for cervical lymphadenopathy, and piperacillin/tazobactam for Serratia marcescens infection [not all routes stated; dosage not stated]. The boy presented to emergency department (ED) with two weeks history of cervical lymphadenopathy and fever. Ten days prior to the current presentation, he had presented to his paediatrician and was subsequently referred to the local ED. He was diagnosed with peritonsillar abscess, and treated with clindamycin for 6 days; however, no improvement was noted in the cervical lymphadenopathy. After that, he was discharged on oral clindamycin, and was suggested to follow up with ENT on outpatient basis. Later, due to lack of clinical improvement with recurrent febrile episodes, the paediatrician recommended for a second consultation and medical management. Therefore, he was hospitalised. At the time of admission, his body temperature was 36.2°C, HR was 124 bpm, oxygen saturation was 98% on room air and the RR was 28. Physical examination showed a large palpable non-fluctuant mass on the right and left sides of the neck. Laboratory tests showed the following: erythrocyte sedimentation rate 73 mm/h, WBC count 11.9×109 cells ( with 63% neutrophils) and CRP 38.59 mg/L. A contrast CT scan of the neck showed a right palatine tonsil with the fluid collection and bilateral enlarged cervical lymph nodes. Therefore, after consultation with infections disease team, he was commenced on piperacillin/tazobactam. Despite the piperacillin/tazobactam treatment, he continued to experience spikes of fevers on day 2. The ENT team performed drainage of the peritonsillar abscess and fine-needle aspiration of the lymph node. They reported that the abscess consisted of a material with cheesy-like consistency, and required to be scraped out rather than drained. On hospitalisation day 5, culture tests led to the identification of Serratia marcescens, which was sensitive to piperacillin/tazobactam. Therefore, treatment with piperacillin/tazobactam was continued. In the following weeks, culture tests turned negative, but he continued to experienced febrile episodes and significant lymph node swelling. Due to the identification of an unusual pathogen and high association with chronic granulomatous disease (CGD), diphenhydramine (DHR) test was performed. Excisional biopsy was also performed due to concerns of malignancy. The pathology examination showed a necrotic granulomatous lymphocytic tissue with histiocytic clusters that strongly stained positive for S100 and CD68, indicative of Rosai-Dorfman disease. Malignancy was ruled out. Eventually, the boy’s antibacterial therapy was changed to tobramycin, meropenem and itraconazole due to suspicion of persistent CGD due to the Serratia infection. Improvement was noted in his condition on day 28, as his CRP level normalised and fever subsided. Therefore, he was discharged on a 10 day course of amoxicillin/clavulanic-acid. During follow up examination af