The article describes a rare case of a 71-year-old woman with deep low back and left flank pain along with persistent high fever of 1 week duration, unresponsive to systemic anti-infective therapy. Dual-energy CT revealed multiple bilateral gouty nodules around the ilium, sacrum, and proximal femur. MRI with contrast showed a large hyperdense cystic lesion along the iliopsoas muscle and erosion of the left sacroiliac joint. After open surgical intervention via a para-rectus approach, milky tophi were scraped from the cystic lesion, pathology confirmed gout, and high-throughput gene sequencing detected mycobacterium tuberculosis without other pathogens. The diagnosis was a pyogenic psoas abscess caused by gout of the iliopsoas muscle in combination with a tuberculous infection. The patient responded well to treatment against gout and tuberculosis with an uncomplicated recovery. Gout of the iliopsoas muscle combined with tuberculosis is extremely rare and may mimic pelvic abscesses. High-throughput gene sequencing is useful for identifying the pathogen, and open surgical drainage through the para-rectus approach is an effective procedure.