Context A young lady presents to emergency gynaecology with acute onset severe pelvic pain. All observations were normal. The negative clinical signs did not correlate to the patientâ€™s severity of symptoms. A pelvic scan showed free fluid and a small simple cyst. A ruptured cyst is possible, but the pain persisted despite analgesia. It was decided to do a laparoscopy and cystectomy as it was assumed to be the cause of pain. Findings at laparoscopy were of widespread infective process, abundant pus, an inflamed turgid appendix, and a small cyst. Without the laparoscopy, it would not have been possible to diagnose this severe inflammatory process. Objective To present an interesting and rare case of Streptococcus Avium infection. To show that sometimes the diagnosis does not match the signs and symptoms. Methods – Case report Patient A 33-year-old lady presented with a short history of offensive vaginal discharge, and lower abdominal pain worsening over the last 24 hours. A copper coil was in situ for 6 years. All vital signs were normal, and on examination, the abdomen was soft with diffuse mild tenderness. Urinalysis was unremarkable and a pregnancy test negative. Blood results included a normal white cell count and inflammatory markers. The coil was removed and the patient was treated as pelvic inflammatory disease. Intervention The pain worsened overnight, and a scan done showed extensive free fluid a 5 cm right ovarian simple cyst. Emergency laparoscopy showed a turgid inflamed appendix with copious pus in the peritoneal cavity, as well as the simple ovarian cyst noted on ultrasound. Appendectomy, right partial salpingectomy and cystectomy was done. The patient made a rapid recovery. Results Strep Avium cultured from pus. A negative HIV test ruled out immunosuppression. Conclusions This patient had a significant infective process, but despite this, vital parameters and temperature were normal throughout, as well as all blood investigations. The case demonstrated our reliance, as clinicians, on blood tests and vital parameters for assessment of severity of disease. In this instance results were misleading. It is easy to assume that with our knowledge we should be able to diagnose pathology, and if we canâ€™t match the signs and symptoms, we may wrongly assume the patient is making it all up. Streptococcus Avium is an unusual pathogenic microbe. Case reports documenting its isolation as a potential cause of significant infection are rare.