Clinically lesser known entity in India: A Report of two cases of Melioidosis

Melioidosis is endemic in the South Asian regions, like Thailand, Singapore Malaysia and Australia. The disease is more pronounced in the southern part of the country. It is caused by Burkholderia pseudomallei which causes systemic involvement, morbidity and mortality associated with the disease is high. Due to highly varied clinical presentation, and low general awareness this infection is largely underdiagnosed and under reported in our country. Most laboratories in the country still rely on conventional culturing methods with their low sensitivity, adding to the under reporting. To enhance physician awareness we describe here two cases who presented to our institute after months of misdiagnosis.     

Retrospective Study on Fatal Melioidosis in Captive Zoo Animals in Thailand

Melioidosis is caused by Burkholderia pseudomallei and is an important zoonotic infectious disease causing high mortality from fulminant septicaemia in humans and a wide variety of animal species. The incidence of fatal melioidosis in zoo animals has been significant in many Thai zoos. A total number of 32 cases were evaluated throughout the Thai zoo animal populations. The highest prevalence of disease has been reported from the north‐eastern region followed by the zoos in the southern part of the country, approximately 47% and 38%, respectively, while the other zoos reported sporadic infections. Herbivores and non‐human primates were the most commonly affected animals with incidences of 59% and 28%, respectively. This appears to be a seasonal correlation with the highest incidence of melioidosis in zoo animals reported in the rainy season (44%) or subdivided monthly in June (19%) followed by September and November (16% and 12%, respectively). The route of infection and the incubation period still remain unclear. This retrospective study examined the clinical presentation in various zoo species, pathological findings and epidemiological data as well as conducting an in depth literature review.     

Cranial melioidosis with extradural extension after a fall in the bathroom

A 32-year-old diabetic male, with a past history of head injury and seizures, presented with a painful swelling over his forehead present for the past three months. Cranial MRI demonstrated the presence of a scalp collection with extradural extension through a bony defect. Biopsy from the area showed caseating necrosis suggestive of tuberculosis. Although the patient failed to return for initiation of anti-tubercular therapy for the next 11 months, the swelling did not progress, and there were no constitutional symptoms. The indolent nature of the swelling prompted re-evaluation and delayed cultures of pus from the collection grew Burkholderia pseudomallei.     

Imported Melioidosis in South Korea: A Case Series with a Literature Review

Objectives

Melioidosis is a potentially fatal infectious disease caused by the environmental anaerobic Gram-negative bacillus Burkholderia pseudomallei. Melioidosis is endemic to areas of northern Australia and Southeast Asia. With increasing international travel and migration, imported cases of melioidosis are being reported regularly. Here, we summarize the 11 cases of melioidosis reported in South Korea from 2003 to 2014.

Methods

Tracing epidemiological investigations were performed on every patient reported to the National Surveillance System since 2011. A systematic literature search was performed to identify melioidosis cases that occurred prior to 2011.

Results

The overall fatality rate was 36.4%. All the patients had visited Southeast Asia where melioidosis is endemic. The stay in the endemic region ranged from 4 days to 20 years. Of the seven patients who developed initial symptoms after returning to South Korea, the time interval between returning to South Korea and symptom onset ranged from 1 day to 3 years. The remaining four patients developed symptoms during their stay in the endemic region and were diagnosed with melioidosis in South Korea. Seven (63.6%) patients possessed at least one risk factor, all of whom were diabetic. Pneumonia was the most frequent clinical manifestation, but the patients showed a wide spectrum of clinical features, including internal organ abscesses, a mycotic aneurysm of the aorta, and coinfection with tuberculosis.

Conclusion

An early diagnosis and initiation of the appropriate antibiotics can reduce the mortality of melioidosis. Consequently, increased awareness of the risk factors and clinical features of melioidosis is required.     

Attempted Passive Prophylaxis with a Monoclonal Anti-Burkholderia Pseudomallei Exopolysaccharide Antibody in a Murine Model of Melioidosis

Melioidosis is a severe gram-negative infection caused by the facultative intracellular bacterium Burkholderia pseudomallei, which is responsible for a broad spectrum of symptoms in both humans and animals. No licensed vaccine currently exists. This study evaluated the protective effect of a monoclonal antibody (Mab Ps6F6) specific to B. pseudomallei exopolysaccharide in an outbred murine model of sub-acute melioidosis. When administered before the infectious challenge, Ps6F6 significantly increased resistance to infection and restrained bacterial burden in the spleen over a 30-days period. Patterns of IFN-γ production were similar in the treated and non treated groups of mice. However, Ps6F6 lowered IFN-γ levels over the duration of the assay period, except on day 1, suggesting a transient and rapid production of IFN-γ under Ps6F6 control. Minor but persisting increases occurred in IL-12 levels while TNF-α was detected only in the controls at the later stages of infection. No IL-10 secretion was detected in both groups of mice. These data suggest that passive prophylaxis with Mab Ps6F6 provide a moderate and transient induction of inflammatory responses in infected mice but failed to trigger a sterilizing protective immunity.     

35例类鼻疽病例临床特点分析

目的分析类鼻疽的临床特点,并探讨其诊断及治疗的方法。方法回顾性分析某院2012年3月—2017年2月收治的有明确病原学依据的35例类鼻疽患者。结果 35例类鼻疽患者在入院时2例(5.7%)因有外院培养结果而确诊,3例(8.6%)高度疑似患者主要有相对典型的临床特点,误诊30例(85.7%),疑似患者入院后均经各种标本培养检出类鼻疽伯克霍尔德菌确诊;采用抗感染、外科穿刺引流(11.4%)及手术(20.0%)治疗,病情好转或痊愈26例(74.3%),放弃治疗2例(5.7%),死亡7例(20.0%)。临床首发症状以发热(88.6%)最常见,其次为咳嗽(34.3%)、气促(28.6%)、腹痛(14.6%)、上下肢痛(11.4%)、关节痛(5.7%);感染部位居前五位的分别为血液(85.7%)、肺(54.3%)、脾(20.0%)、皮肤软组织(20.0%)、肝(14.3%);以血培养出类鼻疽伯克霍尔德菌最为常见,占85.7%,其次为各种穿刺液(37.1%)、痰(20.0%)。结论类鼻疽的临床特点复杂多样,误诊率高,早期确诊和及时、合理、足疗程的治疗可降低病死率和复发率。     

Pacemaker infection secondary to burkholderia pseudomallei

Infection is a relatively rare but devastating complication of intracardiac device implantation. Burkholderia pseudomallei is the organism which causes melioidosis, an endemic and lethal infection in the tropics. We describe a case of pacemaker infection secondary to Burkholderia pseudomallei, which was treated by explantation of the device and appropriate antimicrobial therapy.     

An audit of the use of granulocyte colony-stimulating factor in septic shock

Background: Granulocyte colony‐stimulating factor (G‐CSF) stimulates the production of neutrophils and modulates the function and activity of developing and mature neutrophils. In septic shock, the immune system can be considered one of the failing organ systems.G‐CSF improves immune function and may be a useful adjunctive therapy in patients with septic shock. Aim: To evaluate the introduction of G‐CSF as an adjunct to our standard treatment for community‐acquired septic shock. Methods: We performed a prospective data collection and analysis to determine whether the addition of G‐CSF to our standard treatment for community‐acquired septic shock was associated with improved hospital outcome, compared with an historical cohort ofsimilar patients. We included all patients admitted to the Intensive Care Unit (ICU) with community‐acquired septic shock between December 1998 and March 2000. Patients received 300 µg G‐CSF intravenously daily for 10 days in addition to ourstandard treatment for community‐acquired septic shock. G‐CSF was discontinued early if the patient was discharged from ICU before10 days or if the absolute neutrophil count exceeded 75 × 10⁶/mL. Results: A total of 36 patients with community‐acquired septic shock, an average Apache 2 score of 26.7, and a predictedmortality of 0.79, were treated with G‐CSF from December 1998 to March 2000. Hospital mortality was 31% compared with an historical cohort of 11 similar patients with a hospital mortality of 73% (P = 0.018). In the subgroup of patients with melioidosis septic shock, the hospital survival improved from 5% to 100% (P < 0.0001).No significant adverse events occurred as a result of the administration of G‐CSF. Conclusion: G‐CSF is a safe adjunctive therapy in community‐acquired septic shock and may be associated with improved outcome. The use of G‐CSF in septic shock should undergo further investigation to define subgroups of patients who may benefit from G‐CSF. The use of G‐CSF in patients with septic shock due to Burkholderia pseudomallei is recommended. (Intern Med J 2002; 32: 143?148)     

Pharmacokinetic-pharmacodynamic evaluation of ceftazidime continuous infusion vs intermittent bolus injection in septicaemic melioidosis

AIMS: Experimental studies have suggested that constant intravenous infusion would be preferable to conventional intermittent bolus administration of beta-lactam antibiotics for serious Gram-negative infections. Severe melioidosis (Burkholderia pseudomallei infection) carries a mortality of 40% despite treatment with high dose ceftazidime. The aim of this study was to measure the pharmacokinetic and pharmacodynamic effects of continuous infusion of ceftazidime vs intermittent bolus dosing in septicaemic melioidosis. METHODS: Patients with suspected septicaemic melioidosis were randomised to receive ceftazidime 40 mg kg-1 8 hourly by bolus injection or 4 mg kg-1 h-1 by constant infusion following a 12 mg kg-1 priming dose to perform estimation of pharmacokinetic and pharmacodynamic parameters. RESULTS: Of the 34 patients studied 16 (59%) died. Twenty patients had cultures positive for B. pseudomallei of whom 12 (60%) died. The median MIC90 of B. pseudomallei was 2 mg l-1, giving a target concentration CT, of 8 mg l-1. The median (range) estimated total apparent volume of distribution, systemic clearance and terminal elimination half-lives of ceftazidime were 0.468 (0.241-0.573) l kg-1, 0.058 (0.005-0.159) l kg-1 h-1 and 7.74 (1.95-44.71) h, respectively. Clearance of ceftazidime and creatinine clearance were correlated closely (r = 0. 71; P < 0.001) and there was no evidence of significant nonrenal clearance. CONCLUSIONS: Simulations based on these data and the ceftazidime sensitivity of the B. pseudomallei isolates indicated that administration by constant infusion would allow significant dose reduction and cost saving. With conventional 8 h intermittent dosing to patients with normal renal function, plasma ceftazidime concentrations could fall below the target concentration but this would be unlikely with a constant infusion. Correction for renal failure which is common in these patients is Clearance = k * creatinine clearance where k = 0.072. Calculation of a loading dose gives median (range) values of loading dose, DL of 3.7 mg kg-1 (1. 9-4.6) and infusion rate I = 0.46 mg kg h-1 (0.04-1.3) (which equals 14.8 mg kg-1 day-1). A nomogram for adjustment in renal failure is given.