Melioidosis as a rare cause of deep surgical site infection in a Filipino patient with Metastatic Spinal Disease: A case report

Background@#Melioidosis is a potentially fatal disease caused by Burkholderia pseudomallei. Over a century after its discovery, there seems to be a paucity of reported cases in the Philippines relative to other countries where it is found to be endemic. This suggests that the true burden of melioidosis in the country is not well-defined. The rarity of the disease, its protean clinical manifestations, and the lack of pathognomonic features pose a great diagnostic challenge. Furthermore, the proper recognition of the organism is an extreme necessity as it is intrinsically resistant to numerous antibiotics and requires specific long-term treatment.@*Case@#This is a case of a 49-year-old Filipino diagnosed with a metastatic spinal disease from a primary thyroid carcinoma and underwent posterior spinal decompression and stabilization. Revision of instrumentation was done following identification of an implant loosening. During the interim, wound dehiscence and infection developed. The patient was readmitted and underwent debridement of the lumbosacral spine. Wound cultures all yielded growth of Burkholderia pseudomallei. The patient received meropenem and then trimethoprim-sulfamethoxazole with ciprofloxacin during the intensive and eradication phase, respectively. Erythrocyte sedimentation rate and C-reactive protein were monitored and a significant reduction in both values reflected a good therapeutic response.@*Conclusion@#This is a rare case of a deep surgical site infection caused by Burkholderia pseudomallei. It is known that melioidosis is a potentially fatal infection but is under-reported in the Philippines. At present, further epidemiological studies along with an increased level of awareness of melioidosis are greatly needed to help define the true burden of illness and optimize patient management following prompt recognition.

Melioidosis con endocarditis de válvula protésica / Prosthetic valve endocarditis in melioidosis: case report

Resumen La melioidosis es endémica en varias regiones, con predominio en el Sudeste Asiático, norte de Australia, sur de Asia, China y Taiwán. En Sudamérica, Colombia ocupa el segundo lugar de casos de melioidosis, después de Brasil. Su manifestación clínica es variable, desde una infección asintomática hasta un compromiso multiorgánico con formación de abscesos múltiples y choque séptico. El compromiso cardiaco es inusual, con una incidencia menor del 1%. Se presenta el caso de un varón de 51 años, colombiano, con antecedente de una valvula aórtica mecánica, quien presentó un absceso en la pierna derecha y en la válvula cardiaca protésica, aislándose Burkholderia pseudomallei en hemocultivos y en el cultivo de secreción de la pierna. Fue tratado con meropenem y cotrimoxazol, con una adecuada respuesta clínica, requiriendo un reemplazo valvular aórtico.

Abstract Melioidosis is an endemic disease to several regions and occurs predominantly in Southern Asia, Northern Australia, China and Taiwan. In South America, Colombia is second after Brazil in number of melioidosis cases reported. Clinical manifestation varies from asymptomatic infection to multiorgan compromise involving multiple abscesses and septic shock. Cardiac compromise is infrequent, with an incidence of <1%. We report the case of a 51-year-old patient from Colombia with a mechanical aortic valve who had an abscess in right leg and in the prosthetic valve. Burkholderia pseudomallei was isolated in blood cultures and drained pus from the leg cultures. Patient was treated with meropenem and cotrimoxazole and required aortic valve replacement, resulting in adequate improvement in clinical symptoms.

Melioidosis en Colombia, descripción de un caso clínico y consideraciones epidemiológicas / Melioidosis in Colombia, description of a clinical case and epidemiological considerations

Resumen La melioidosis es una enfermedad infecciosa causada por Burkholderia pseudomallei cuyo diagnóstico clínico puede ser difícil debido a su variada presentación clínica y a las dificultades del diagnóstico microbiológico, por lo cual pueden requerirse técnicas moleculares para su adecuada identificación una vez se sospecha su presencia. Son pocos los antibióticos disponibles para el tratamiento de esta enfermedad y, además, deben usarse durante un tiempo prolongado. Aunque se conoce por ser endémica en Tailandia, Malasia, Singapur, Vietnam y Australia, en Colombia se han reportado algunos pocos casos. Se presenta un caso de melioidosis en la región norte de Colombia, se hace una revisión de las características clínicas y el tratamiento, y se describe la epidemiología local de esta enfermedad.

Abstract Melioidosis is an infectious disease caused by Burkholderia pseudomallei whose clinical diagnosis can be difficult due not only to its varied clinical presentation but also to the difficulties in the microbiological diagnosis.Thus, it may be necessary to use molecular techniques for its proper identification once it is suspected. There are few antibiotics available for the treatment of this disease, which must be used over a long period of time. Although it is known to be endemic in Thailand, Malaysia, Singapore, Vietnam, and Australia, in Colombia there are few reported cases. We describe a case of melioidosis in the northern region of Colombia. Additionally, we review its clinical characteristics and treatment and we describe the local epidemiology of this disease.

Melioidosis en paciente del sudeste asiático / Melioidosis in a Southeast Asian patient

La melioidosis es una enfermedad infecciosa causada por una bacteria gram-negativa intracelular facultativa, Burkholderia pseudomallei, que se encuentra en el suelo y el agua. Es de importancia para la salud pública en las zonas endémicas, sobre todo el sudeste asiático. Se han descrito casos fuera de las regiones endémicas en su mayoría adquiridos por los visitantes a estas áreas. Se presenta el caso de un paciente masculino con sintomatología respiratoria, elementos de sepsis y contracción volumétrica, en el que se diagnosticó diabetes mellitus de debut, neumonía adquirida en la comunidad y finalmente se aisló en hemocultivo la Burkholderia pseudomallei. Se comenzó tratamiento recomendado acorde al antibiograma, observándose evolución satisfactoria del paciente(AU)

Melioidosis is an infectious disease caused by a facultative intracellular gram-negative bacterium, Burkholderia pseudomallei, found in soil and water. It is of importance for public health in endemic areas, especially Southeast Asia. Cases have been described outside the endemic regions, mostly acquired by visitors to these areas. The case is presented of a male patient with respiratory symptoms, elements of sepsis and volumetric contraction, in which the diagnosis of onset diabetes mellitus and community-acquired pneumonia, while Burkholderia pseudomallei was finally isolated in hemoculture. The recommended treatment was started according to the antibiogram, observing the patient's satisfactory evolution(AU)

Clinical Outcomes in Musculoskeletal Involvement of Burkholderia Pseudomallei Infection

BACKGROUND: Musculoskeletal involvement in melioidosis is often seen in conjunction with a disseminated illness. Recent reports suggest that operative management of musculoskeletal melioidosis has favourable results. The purpose of this study was to review the patient profile and clinical outcomes of Burkholderia pseudomallei infection in the musculoskeletal system. METHODS: Hospital records of 163 patients who were diagnosed to have B. pseudomallei infection between January 2009 and December 2014 were reviewed. Patients underwent surgical and nonsurgical management depending upon the tissue of involvement. Epidata software was used to record the data. The SPSS ver. 17.0 was used for analysis. RESULTS: Eighteen out of 24 patients who had musculoskeletal melioidosis were available for follow-up. Septic arthritis, osteomyelitis, and intramuscular abscess were the common diagnosis, with 6 patients in each group. Twelve patients required surgical intervention. All patients received a full course of parenteral ceftazidime followed by oral doxycycline and co-trimoxazole. Two out of 6 patients (33.3%) died among those who had nonsurgical management as compared to none in the group who had surgical management. This was significant at 10% level of significance (p = 0.098). The rest were followed up for a minimum of 1 year with no evidence of disease recurrence. CONCLUSIONS: This series describing musculoskeletal involvement in melioidosis is the largest such study from a recently recognized ‘endemic’ region. Of importance are the patterns of musculoskeletal involvement, pitfalls in diagnosis and adequate clinical response with timely diagnosis and appropriate surgical management.

Neurological melioidosis in East Malaysia: Case series and review of the literature

Melioidosis is an infectious disease caused by an aerobic, non-spore forming gram negative bacillus, Burkholderia pseudomallei. It is known to be of high incidence in parts of rural South East Asia, and in Northern Australia. Pneumonia is the commonest manifestation. We report here three cases of neurological melioidosis from the registry of 169 cases of melioidosis in Bintulu Hospital, Sarawak, East Malaysia, with a review of neurological melioidosis in the literature. The annual incidence of melioidosis is estimated to be 8 per 100,000 populations in the Bintulu district. Neurological melioidosis accounts for 1.8% of our melioidosis cases. A review of 76 cases of neurological melioidosis reported in the literature inclusive of our 3 cases shows that localized brain or spinal inflammation or abscess is the most common manifestation occurring in 80% of patients. Close to half (53%) have intra axial abscess (brain or spinal cord), a quarter (27%) have extra axial lesions only (epidural or subdural collection, osteomyelitis or scalp abscess), and another quarter (27%) have both intra and extra axial lesions. Thus, B. pseudomallei appears to be unique among the bacterial central nervous system infection to be able to affect the brain and its contiguous tissues, crossing the tissue plane particularly resulting in osteomyelitis, scalp abscess and vice versa. Two thirds of the neurologicalmelioidosis patients have only neurological disease with no evidence of disease elsewhere. Key words: Burkholderia pseudomallei; neurological melioidosis; Bintulu; Sarawak; Malaysia

Pediatric suppurative parotitis caused by Burkholderia pseudomallei

Background: Suppurative parotitis caused by Burkholderia pseudomallei has been rarely found outside endemic areas. Case presentation: Herein, we report the recovery of Burkholderia pseudomallei from the pus of a suppurative parotitis observed in a 12-year-old boy who lived in Hainan province, China. Specimens of necrotic tissue were collected and sections were stained with hematoxylin and eosin. Pus sample was also collected for bacteriological examination. The suppurative inflammation was observed in the necrotic tissue section and Burkholderia pseudomallei were detected in the sample. Conclusion: In this adolescent, Burkholderia pseudomallei infection was present in the parotid, which consists of the first report of this bacterium in a parotitis case acquired in China.(AU)

Melioidosis parotitis in children

A recent paper published in JVATiTD reporting a child in Hainan with parotitis caused by Burkholderia pseudomallei misleadingly described parotitis as a rare manifestation of melioidosis. In fact, it is one of the commonest forms of paediatric melioidosis seen in other parts of Southeast Asia, although interestingly not in Australia.(AU)

Melioidosis parotitis in children

A recent paper published in JVATiTD reporting a child in Hainan with parotitis caused by Burkholderia pseudomallei misleadingly described parotitis as a rare manifestation of melioidosis. In fact, it is one of the commonest forms of paediatric melioidosis seen in other parts of Southeast Asia, although interestingly not in Australia.

Pediatric suppurative parotitis caused by Burkholderia pseudomallei

Suppurative parotitis caused by Burkholderia pseudomallei has been rarely found outside endemic areas. Case presentation: Herein, we report the recovery of Burkholderia pseudomallei from the pus of a suppurative parotitis observed in a 12-year-old boy who lived in Hainan province, China. Specimens of necrotic tissue were collected and sections were stained with hematoxylin and eosin. Pus sample was also collected for bacteriological examination. The suppurative inflammation was observed in the necrotic tissue section and Burkholderia pseudomallei were detected in the sample. Conclusion: In this adolescent, Burkholderia pseudomallei infection was present in the parotid, which consists of the first report of this bacterium in a parotitis case acquired in China.

Non-Caseating Granulomatous Infective Spondylitis: Melioidotic Spondylitis

STUDY DESIGN: Retrospective clinical analysis. PURPOSE: To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. OVERVIEW OF LITERATURE: Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei, has been labeled as a bio-terrorism agent. METHODS: We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels. RESULTS: Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up. CONCLUSIONS: Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.

A Case of Ceftazidime-Nonsusceptible Burkholderia pseudomallei Infection

Melioidosis, which is an infectious disease caused by Burkholderia pseudomallei, is prevalent mostly in Southeast Asia and northern Australia; it can progress to abscess formation, pneumonia and sepsis, and ultimately cause death. A 66-yr-old male patient with diabetes mellitus was hospitalized for sepsis 3 months after coming back from Cambodia, and B. pseudomallei was identified from the blood culture. The B. pseudomallei strain was found to be susceptible to carbapenem, and non-susceptible to trimethoprim/sulfamethoxazole and ceftazidime. Although the patient was treated with carbapenem, to which the strain was susceptible, the bacteremia persisted, and progressed to septic shock and pneumonia, and eventually to acute respiratory distress syndrome (ARDS). The patient died on the 12th day of hospitalization. This study, which reports the first case of ceftazidime-nonsusceptible B. pseudomallei in Korea, indicates the importance of B. pseudomallei infection, which is highly likely to be imported to Korea, and discuss its clinical progress, which can lead to fatality.

A forgotten disease of Myanmar origin.

A 16-year old student from Taungoo presented to medical ward, Insein General Hospital with one month-long fever, weight loss and multiple abscesses and ulcers at the face, limbs and trunk. Examination revealed pallor, remittent fever and hepatosplenomegaly. Imaging showed multiple splenic abscesses. Wound swab cultures from ulcers revealed gram negative coccobaccilli with characteristic of Burkholderia pseudomallei. The diagnosis was melioidosis. Defeverese time was 13 days after treatment with intravenous ceftazidime and amikacin. Recovery was uneventful. This case warrants the clinician, in case of recalcitrant septicaemia, to consider melioidosis-originally discovered in Myanmar but uncommon now.

Melioidosis: A report of two cases.

Melioidosis is increasingly being reported from India in the past few years. Since it can mimic tuberculosis during the initial presentation, treatment with antituberculosis drugs is common. It should be considered in the differential diagnosis of any pyrexia of unknown origin. We report two cases of melioidosis that presented with pyrexia of unknown origin and a localized cutaneous abscess over the chest wall.

Colonization or spontaneous resolution: expanding the role for Burkholderia pseudomallei

A 19-year-old Asian Indian female presented with productive cough since the past one month and low grade fever since the past two weeks. She was diagnosed with pulmonary tuberculosis and treated with antitubercular drugs. Subsequently, delayed cultures of bronchoalveolar lavage fluid grew Burkholderia pseudomallei (B. pseudomallei). On follow up the patient reported significant subjective improvement and ESR progressively returned to normal. In summary, this case report raises two distinct and equally intriguing roles for B. pseudomallei, i.e. respiratory colonization and spontaneously resolving pulmonary infection. The pathogenic potential of B. pseudomallei, the etiologic agent of melioidosis, is well known. Confirmation of either colonization or spontaneous resolution, would potentially spare many patients unnecessary and expensive therapy with broad-spectrum antibiotics, and contribute to more rational usage of antibiotics, especially in co-infection with Mycobacterium tuberculosis and B. pseudomallei-two bacterial diseases with closely similar clinical, radiologic and histopathologic features.

Tos y disnea de seis años de evolución en un adulto joven con melioidosis pulmonar crónica. Reporte de caso / Cough and dyspnea during six years in a young adult with chronic pulmonary melioidosis: Case report

Resumen: La melioidosis es una enfermedad infecciosa causada por una bacteria gram-negativa intracelularBurkholderia pseudomallei. Este microorganismo es un saprofito ambiental en regiones endémicas,algunas de ellas ubicadas probablemente en el territorio nacional y presenta alto riesgo de propagación como epidemia en zonas no endémicas. La melioidosis es una enfermedad clínicamente diversa, la mayoría de las infecciones son asintomáticas; sin embargo, si el paciente es sintomático, se puede clasificar como aguda o crónica según su persistencia. La presentación clínica más común es la afectación pulmonar y al diagnóstico predominan baciloscopias persistentemente negativas. Aquí se presenta un caso de un paciente con tos crónica, expectoración mucopurulenta, sudoración nocturna y disnea.

Abstract: Melioidosis is an infectious disease caused by the intracellular gram-negative bacterium Burkholderia pseudomallei. This microorganism is an environmental saprophyte in endemic regions, some of which are likely located in our country and have a high risk of spreading to non-endemic areas. Melioidosis is a clinically diverse disease. Most infections are asymptomatic; however, if symptoms are present, the disease can be classified as acute or chronic according to persistence of symptoms. In addition, lung involvement is the most common clinical presentation and one of the main diagnostic features is consistently negative bacilloscopy. Here we present a case report of a patient with chronic cough, mucopurulent expectoration, night sweats and dyspnea.

Severe coinfection of melioidosis and dengue fever in northeastern Brazil: first case report / Coinfecção grave de melioidose e dengue no nordeste do Brasil: primeiro caso

This report focuses on a fatality involving severe dengue fever and melioidosis in a 28-year-old truck driver residing in Pacoti in northeastern Brazil. He exhibited long-term respiratory symptoms (48 days) and went through a wide-ranging clinical investigation at three hospitals, after initial clinical diagnoses of pneumonia, visceral leishmaniasis, tuberculosis, and fungal sepsis. After death, Burkholderia pseudomallei was isolated in a culture of ascitic fluid. Dengue virus type 1 was detected by polymerase chain reaction in cerebrospinal fluid (CSF); this infection was the cause of death. This description reinforces the need to consider melioidosis among the reported differential diagnoses of community-acquired infections where both melioidosis and dengue fever are endemic.

Estudo de caso fatal de coinfecção de melioidose e dengue grave em um motorista de 28 anos, residente no município de Pacoti, nordeste do Brasil. O paciente apresentou inicialmente sintomas respiratórios com evolução por 48 dias. Foi internado em três diferentes unidades de saúde com suspeitas de pneumonia, leishmaniose visceral, tuberculose e sepse fúngica. Após o óbito, a cultura de líquido ascítico identificou a bactéria Burkholderia pseudomallei. O vírus da dengue tipo 1 foi detectado por PCR no líquor do paciente. Esta descrição reforça a necessidade de considerar a melioidose entre os diagnósticos diferenciais de infecções comunitárias onde as duas doenças são endêmicas.

Ceftazidime resistance in Burkholderia pseudomallei: first report from India

Melioidosis, a disease of public health importance in Southeast Asia and Northern Australia, of late has shown an increasing trend in India, particularly Southern India. We describe a case of a 39-year-old diabetic patient with left elbow septic arthritis, multiple liver, splenic abscesses, pneumonia, pleural effusion, followed by sepsis syndrome. Blood cultures and culture of the joint aspirate yielded pure growth of Burkholderia pseudomallei (B. pesudomallei), sensitive to carbapenem, co-trimoxazole and resistant to ceftazidime. The patient was successfully treated with imipenem- cilastin. He was discharged on co-trimoxazole to complete the 24 weeks course and follow-up has continued to date. The patient continues to remain asymptomatic. The case re-emphasizes the need to monitor the trend of B. pseudomallei in India, particularly the development of ceftazidime resistance, which incidentally is the drug of choice.

Septicemic Melioidosis Presenting as Head and Neck Abscesses

Melioidosis is a life-threatening disease caused by Burkholderia pseudomallei , which is endemic in Southeast Asia and Northern Australia. It may manifest as a pulmonary lesion, osteomyelitis, septicemia, or abscesses of soft tissue or various organs. However, soft tissue abscess associated with bacteremia, especially those found in the head and neck, are rarely reported. We report a case of disseminated septicemia due to Burkholderia pseudomallei presenting as head and neck abscesses in a 55-year-old Korean man with a history of working in Malaysia. This is the first report of fatal melioidosis presenting as a complicated skin and soft tissue infection, in Korea.