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PICTORIAL EDUCATION  
Year : 2011  |  Volume : 3  |  Issue : 2  |  Page : 183-186
Melioidosis: A case report


Super Religare Laboratories Ltd, Fortis Flt. Rajan Dhall Hospital, Vasant Kunj, New Delhi, India

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Date of Web Publication27-May-2011
 

   Abstract 

Burkhloderia pseudomallei has recently gained importance as an emerging pathogen in India. It causes various clinical manifestations like pneumoniae, septicaemia, arthritis, abscess etc. Cases have been reported from Southeast Asia mainly Thailand, Malaysia, Vietnam, etc. In India, few cases have been reported mainly from the southern part of the country. Patient was a 65-year-old male and presented with fever 1 month back, cough and breathlessness for same period, swelling on both ankles from 7 days. B. pseudomallei was isolated from endotracheal secretions, blood cultures, leg wound. He was successfully treated with Imipenem and Doxycycline and put on maintenance therapy now, and is currently doing well.

Keywords: Burkhlorderia pseudomallei , Imipenem, Melioidosis, Septicaemia

How to cite this article:
Barman P, Sidhwa H, Shirkhande PA. Melioidosis: A case report. J Global Infect Dis 2011;3:183-6

How to cite this URL:
Barman P, Sidhwa H, Shirkhande PA. Melioidosis: A case report. J Global Infect Dis [serial online] 2011 [cited 2019 Jul 16];3:183-6. Available from: http://www.jgid.org/text.asp?2011/3/2/183/81697



   Introduction Top


Burkhloderia pseudomallei has off late gained importance as an emerging pathogen in India. It is capable of causing various clinical manifestations like pneumoniae, septicaemia, arthritis, abscess etc. and is associated with high morbidity and mortality. Cases have been reported from Southeast Asian countries like Thailand, Malaysia and Vietnam etc. [1] In India, most cases have so far been reported from the southern states like Kerela [2] and Tamil Nadu. [3] Isolated cases have also been reported from eastern and northeastern parts of India. [2],[4] Alhough not so uncommon in India but early and correct diagnosis and institution of proper antimicrobial therapy is important in order to reduce morbidity and mortality and have a favourable outcome.

Here we report a case of Melioidosis which probably was undiagnosed for long but was saved due to correct and timely intervention.


   Case Report Top


Our patient was a 65-year-old male from the state of Bihar. He presented with swelling of ankles and pain, redness on right ankle for 7 days and fever, cough, breathlessness from last 1 month.

Two months back he was treated for fever with Ceftriaxone as his Widal test was reactive. At about the same time, he was incidentally diagnosed with diabetes mellitus (DM). On treatment, though his symptoms subsided to some extent, during last 7 days he again complained of high fever, worsening breathlessness and loss of appetite. He was then brought to our hospital for further management.

On examination he was toxic, febrile, icteric, and dehydrated. His body temperature was 102° F, blood pressure 90/70mm Hg, respiratory rate 50/min, and heart rate 128/min. Bronchial breath sounds on left side and bilateral crackles were heard. Spleen was mildly enlarged without any free fluid in the abdomen. No cardiovascular or neurological abnormality was noted. On local examination, ankles were erythematic and oedematous. His right foot had cellulites with pustular discharge. His right knee was also swollen.

Laboratory investigations revealed that multiple hematological and biochemical parameters were deranged [Table 1]. Urine and blood samples were sent for culture.
Table 1: Laboratory findings

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His chest X-ray showed homogenous consolidation in upper left lobe and diffuse alveolar opacities in remaining part of lung [Figure 1]. Ultra sound revealed mild bilateral pleural effusion and mild ascitis with enlarged spleen. No focal lesions or organomegaly were noted.
Figure 1: Chest X-ray showing left upper lobe consolidation

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Post admission his condition further deteriorated and had clinical evidences of Acute Respiratory Distress Syndrome, deranged blood gases, and was in respiratory distress. His oxygen saturation was 78%. With this background, he was put on ventilator and started with Piperacillin/Tazobactum and Clindamycin.

On day 2, endotracheal secretion was sent for culture. Gram negative bacilli were seen on gram stain [Figure 2]. Non fermenting pale colonies with metallic sheen were isolated next day on Blood agar and Mac Conkey agar [Figure 3]; the isolate was further processed on Microscan Walkaway 96 Si. Patient was continued with the same antibiotics. His total count, however, further increased to 26,000/cubic mm.
Figure 2: Gram negative bacilli with safety pin appearance on Gram stain

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Figure 3: Colonies of Bukhlorderia pseudomallei on Mac Conkey agar

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On day 4, the isolate was identified as Burkhlorderia pseudomallei, sensitive to Imipenem, Cotrimoxazole/Sulfamethoxazole, Tetracycline and resistant to Ceftazidime. Later on, both his blood cultures and pus drained from right leg [Figure 4] also grew B. pseudomallei. Based on the sensitivity report, antibiotic was changed to a combination of Imipenem and Doxycycline. Patient showed improvement, his fever subsided, total counts decreased, oxygen saturation was 100%, and was extubated on day 8.
Figure 4: Pus drained from right ankle

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His antibiotics were continued and after complete recovery and improvement of his liver and renal parameters he was discharged on day 20.


   Discussion Top


B. pseudomallei is an environmental inhabitant and is widely disseminated in soil, water, paddy fields, etc. It is geographically restricted to tropical and subtropical areas of Australia and Southeast Asian countries. In India, quite a number of cases were reported though many are still underreported due to its protean manifestations. [Table 2] gives a short review of different cases reported from India. Most of these were reported from the southern part though Melioidosis may be more widely prevalent. Two of the cases reported from Tamil Nadu actually originated from eastern part of India. [4] DM has been found to be one of the most frequent predisposing factors. Human infection occurs through inhalation or direct inoculation on damaged skin. Our patient was exposed to recent floods, which could be the source of infection.
Table 2: Review of cases in India

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Active infection have been predisposed to occur in patients with many underlying conditions like DM, renal disease, [6] and HIV postive. [7] In our patient diabetes was an incidental finding during the course of investigation. Vidyalaxmi et al. [6] found a correlation of 76% of diabetes with Melioidosis. Melioidosis is a systemic manifestation with pulmonary involvement as the commonest manifestation. It is also associated with liver and spleen. [8],[9] Bone involvement has been reported in 16% cases by Chiranjay et al. [10] Our case was a typical presentation with pulmonary involvement along with bacteraemia. Splenomegaly was present without abscess formation. Soft tissue involvement was seen though without any bony lesion.

The drug of choice is Ceftazidime in systemic melioidiosis. [12] Review of literature reveals successful treatment with a combination of Ceftazidime and Co-trimoxazole [Table 2]. Our strain was resistant to Ceftazidime and therefore patient was put on Imipenem and Doxycycline. Studies [13],[14] showed that though Ceftazidime is the drug of choice. Carbepenems have a better response against B. pseudomallei.

The patient was put on maintenance therapy of Doxycycline, Trimethoprim -Sulfamethoxazole and is doing well. Studies have documented fatalities even upon institution of therapy or due to late diagnosis. [4],[8]


   Conclusion Top


The case focuses the need to record presence of Melioidosis in India. This case was probably missed due to lack of clinical awareness and correct microbiological diagnosis. A high index of suspicion is needed for diagnosis due to its varied clinical presentations.

At the same time, the case highlights the need for improved microbiology services in patient care management. We were able to successfully treat the case by institution of correct antimicrobials based on microbiology feedback.

 
   References Top

1.Raja NS, Ahmed MZ, Singh NN. Melioidosis: An emerging infectious disease. J Postgrad Med 2005;51:140-5.  Back to cited text no. 1
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2.Anuradha K, Meena AK, Lakshmi V. Isolation of Burkholderia pseudomallei from a case of septicaemia: A case report. Indian J Med Microbiol 2003;21:129-32.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Jesudason MV, Anbarasu A, John TJ. Septicaemic melioidosis in a tertiary care hospital in south India. Indian J Med Res 2003;117:119-21.  Back to cited text no. 3
    
4.Viswaroop BS, Balaji V, Mathai E, Kekre NS. Melioidosis presenting as genitourinary infection in two men with diabetes. J Postgrad Med 2007;53:108-10.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Cherian T, John TJ, Ramakrishna B, Lalitha MK, Raghupathy P. Disseminated melioidosis. Indian Pediatr 1996;33:403-6.  Back to cited text no. 5
[PUBMED]    
6.Vidyalakshmi K, Shrikala B, Bharathi B, Suchitra U. Melioidosis: An under-diagnosed entity in western coastal India: A clinico-microbiological analysis. Indian J Med Microbiol 2007;25:245-8.   Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Balaji V, Rajiv K, Abraham OC. Burkholderia pseudomallei recovered in an HIV-positive individual. Indian J Med Sci 2008;62:456-8.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Mukhopadhya A, Balaji V, Jesudason MV, Amte A, Jeyamani R, Kurian G. Isolated liver abscesss in melioidosis. Indian J Med Microbiol 2007;25:150-1.  Back to cited text no. 8
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9.Dhodapkar R, Sujatha S, Sivasangeetha K, Prasanth G, Parija SC. Burkholderia pseudomallei infection in a patient with diabetes presenting with multiple splenic abscesses and abscess in the foot: A case report. Cases J 2008;1:224.   Back to cited text no. 9
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10.Mukhopadhyay C, Chawla K, Krishna S, Nagalakshmi N, Rao SP, Bairy I. Emergence of Burkholderia pseudomallei and pandrug-resistant non-fermenters from southern Karnataka, India. Trop Med Hyg 2008;102:S12-7.  Back to cited text no. 10
    
11.Noyal MJ, Harish BN, Bhat V, Parija SC. Neonatal melioidosis: A case report from India. Indian J Med Microbiol 2009;27:260-3.  Back to cited text no. 11
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12.Sookpranee M, Boonma P, Susaengrat W, Bhuripanyo K, Punyagupta S. Multicenter prospective randomized trial comparing ceftazidime plus co-trimoxazole with chloramphenicol plus doxycycline and co-trimoxazole for treatment of severe melioidosis. Antimicrob Agents Chemother 1992;36:158-62.   Back to cited text no. 12
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13.Walsh AL, Smith MD, Wuthiekanun V, White NJ. Postantibiotic effects and Burkholderia (Pseudomonas) pseudomallei: Evaluation of current treatment. Antimicrob Agents Chemother 1995;39:2356-8.  Back to cited text no. 13
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14.Cheng AC, Fisher DA, Anstey NM, Stephens DP, Jacups SP, Currie BJ. Outcomes of patients with melioidosis treated with meropenem. Antimicrob Agents Chemother 2004;48:1763-5.  Back to cited text no. 14
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Correspondence Address:
Purabi Barman
Super Religare Laboratories Ltd, Fortis Flt. Rajan Dhall Hospital, Vasant Kunj, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.81697

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]

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[Pubmed]



 

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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
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