Melioidosis in a returned traveller

Melioidosis is an infection endemic to Southeast Asia and Northern Australia, and is associated with significant morbidity and mortality. The present report describes a case of chronic melioidosis in a returning traveller from the Philippines. Clinical suspicion of this illness is warranted in individuals with a history of travel to endemic regions. Safety in handling clinical specimens is paramount because laboratory transmission has been described.     

Tuberculosis mimicked by melioidosis

BACKGROUND: In regions endemic for tuberculosis (TB) such as India, presumptive anti-tuberculosis treatment is often prescribed. Melioidosis, caused by Burkholderia pseudomallei, is underdiagnosed in India, due to lack of awareness and a low index of suspicion. SETTING: A tertiary care hospital in south India. OBJECTIVE: To present our analysis of a series of 22 cases of suspected TB that was later confirmed as melioidosis. DESIGN: Twenty-two patients with culture-proven melioidosis, who were initially given empirical anti-tuberculosis treatment, were retrospectively analysed regarding clinical presentation, laboratory findings and epidemiological features, with a view to determining any significant discriminatory parameter/s that would help distinguish the two diseases. RESULTS: Eight cases mimicked pulmonary TB, five tubercular arthritis, three tubercular spondylitis, two tubercular lymphadenitis, two splenic abscess, and one each mimicked tubercular pericarditis and parotid abscess. Fever was the chief presenting complaint; all had high erythrocyte sedimentation rate (ESR) values (mean 111 mm +/- 23.7 SD); 15 (68.2%) had neutrophilic leuco-cytosis, 20 (90.9%) had diabetes mellitus. Subsequent to laboratory culture reports confirming melioidosis, appropriate treatment was instituted. CONCLUSION: Fever in a diabetic patient with high ESR and neutrophilic leucocytosis should raise suspicion of melioidosis while instituting presumptive anti-tuberculosis treatment in areas where both diseases are prevalent.     

Acute Septicemic Melioidosis Presenting with Acute Cholangitis

Abstract Melioidosis is a disease prevalent in the tropics, especially in Southeast Asia. The most common clinical presentations are bacteremic pneumonia and abscess formation in various organs. Although a wide variety of disease presentations are reported for melioidosis, acute cholangitis has not been previously reported. Herein, we report a 54-year-old woman who had fever, right upper abdominal pain and jaundice 1 week after a flood caused by a typhoon in southern Taiwan. Acute cholangitis and pneumonia with septic shock caused by Burkholderia pseudomallei were subsequently diagnosed.     

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.     

The epidemiology of melioidosis in Australia and Papua New Guinea

Melioidosis was first described in Australia in an outbreak in sheep in 1949 in north Queensland (22 degrees S). Human melioidosis was first described from Townsville (19 degrees S) in 1950. Melioidosis is hyperendemic in the Top End of the Northern Territory (NT) and as in parts of northeastern Thailand it is the commonest cause of fatal community-acquired septicemic pneumonia. In the 9 years since 1989 the prospective NT melioidosis study at Royal Darwin Hospital (12 degrees S) has documented 206 culture confirmed cases of melioidosis, with an average annual incidence of 16.5/100,000. Melioidosis is also seen in the north of Western Australia and north Queensland, including the Torres Strait Islands, but is uncommon in adjacent Papua New Guinea. Serological studies suggest that infection is rare in the Port Moresby region, but there is emerging evidence of melioidosis from Western Province. The NT study has documented inoculating events in 52 (25%) of cases, with an incubation period of 1-21 days (mean 9 days); 84% of cases had acute disease from presumed recent acquisition and 13% had chronic disease (sick, > 2 months). In 4% there was evidence of possible reactivation from a latent focus; 28 of 153 (18%) males had prostatic abscesses. The overall mortality was 21% (43 cases), with a mortality rate in septicemic cases (95) of 39% and in non-septicemic cases (103) of 4%. Pneumonia was the commonest presentation in both groups and, in addition, eight patients (two deaths) presented with melioidosis encephalomyelitis. Melioidosis clusters in temperate Australia are attributed to animals imported from the north. Molecular typing of Burkholderia pseudomallei isolates from temperate southwest Western Australia showed clonality over 25 years. In this outbreak and in studies from the NT, some soil isolates are molecularly identical to epidemiologically related animal and human isolates. Molecular typing has implicated the water supply in two clonal outbreaks in remote aboriginal communities in northern Australia. Further prospective collaborative studies are required to evaluate whether there are truly regional differences in clinical features of melioidosis and to better understand how B. pseudomallei is acquired from the environment.     

Neurologic Melioidosis

Melioidosis is an important cause of morbidity and mortality in northern Australia and Southeast Asia. Diagnosis is best made by isolation of Burkholderia pseudomallei from clinical specimens. A variety of clinical presentations are described, including neurologic disease. The aim of this study was to review admissions with confirmed neurologic melioidosis to a regional hospital in a region to which melioidosis is endemic during 1995–2011. There were 12 culture-confirmed cases of neurologic melioidosis, of which two were detected by analysis of cerebrospinal fluid. Four of these cases were in children. Significant clinical features were fever, headache, and ataxia. Common changes on magnetic resonance imaging T2-weighted scans included ring-enhancing lesions and leptomeningeal enhancement. There were four deaths and an additional four patients had significant long-term neurologic sequelae. When considering the etiology of undifferentiated neurologic disease, an awareness of the possibility of neurologic melioidosis is important in disease-endemic regions.     

Characteristics,clinical outcomes and factors influencing mortality of patients with melioidosis in southern Thailand:a 10-year retrospective study

Objective:To study characteristics,clinical outcomes and factors influencing mortality of patients afflicted with melioidosis.Methods:A total of 134 patients were retrospectively analyzed with a microbiologically-confirmed diagnosis of melioidosis,during the period from January 2002 to June 2011 at Songklanagarind Hospital,a tertiary care hospital in southern Thailand.Results:The prevalence of melioidosis among admitted patients was 36.8 per100000 in patients.The median age was 49 years and they were predominantly male.The most common underlying disease was diabetes mellitus(47.01%).The majority of cases(50%)had localized infection.The rates of multifocal,bacteremic,and disseminated infections were12.7%.23.1%.and 14.2%.respectively.The lungs were the most common organ afflicted,resulting in infection(24.63%).Splenic abscess as well as liver abscess accounted for 20.90%and 19.40%.respectively.A total of one eighth of the patients had septic shock at presentation.The overall mortality rate was 8.96%.The factors influencing mortality were pneumonia,septic shock,a positive blood culture for Burkholderia pseudomallei.superimposing with nosocomial infection and inappropriate antibiotic administration.Conclusions:Melioidosis is not uncommon in southern Thailand.The mortality of patients with pneumonia,bacteremia and septic shock is relatively high.Appropriate antibiotics,initially,will improve outcomes.     

Expect the unexpected: pleuro‐pulmonary melioidosis in a renal transplant recipient

Melioidosis is an infectious disease endemic in tropical northern Australia and Southeast Asia, and, if treated late or inappropriately, is usually fatal. We report a rare case of pleuro‐pulmonary melioidosis with septicemia in a renal transplant recipient to highlight the potential risk of acquiring this infection in at‐risk patients living in, or visiting, regions that are endemic for melioidosis, and to convey the importance of its early diagnosis and specific treatment.     

Melioidosis

Melioidosis, which is infection with the gram-negative bacterium Burkholderia pseudomallei, is an important cause of sepsis in east Asia and northern Australia. In northeastern Thailand, melioidosis accounts for 20% of all community-acquired septicaemias, and causes death in 40% of treated patients. B pseudomallei is an environmental saprophyte found in wet soils. It mostly infects adults with an underlying predisposing condition, mainly diabetes mellitus. Melioidosis is characterised by formation of abscesses, especially in the lungs, liver, spleen, skeletal muscle, and prostate. In a third of paediatric cases in southeast Asia, the disease presents as parotid abscess. In northern Australia, 4% of patients present with brain stem encephalitis. Ceftazidime is the treatment of choice for severe melioidosis, but response to high dose parenteral treatment is slow (median time to abatement of fever 9 days). Maintenance antibiotic treatment is with a four-drug regimen of chloramphenicol, doxycycline, and trimethoprim-sulfamethoxazole, or with amoxicillin-clavulanate in children and pregnant women. However, even with 20 weeks' antibiotic treatment, 10% of patients relapse. With improvements in health care and diagnostic microbiology in endemic areas of Asia, and increased travel, melioidosis will probably be recognised increasingly during the next decade.     

Consensus guidelines for dosing of amoxicillin-clavulanate in melioidosis

Melioidosis is an infectious disease endemic to northern Australia and Southeast Asia. In response to clinical confusion regarding the appropriate dose of amoxicillin-clavulanate, we have developed guidelines for the appropriate dosing of this second-line agent. For eradication therapy for melioidosis, we recommend 20/5 mg/kg orally, three times daily.     

Acute suppurative parotitis caused by Pseudomonas pseudomallei in children

During a prospective clinical study of melioidosis in northeast Thailand, suppurative parotitis was observed as a characteristic presentation in children. Parotitis constituted 6.3% of all culture-positive melioidosis and 38% of melioidosis in children. Nine cases are described. None had apparent predisposition to infection, although two patients developed rising mumps virus antibody titers, suggesting a possible relation between these conditions. Complications included abscess formation (nine), spontaneous rupture into the auditory canal (five), facial nerve palsy (two), and septicemia and osteomyelitis with septic arthritis (one each). All children initially responded to surgical drainage and appropriate antibiotic therapy. Pseudomonas pseudomallei parotitis should be considered in children from endemic areas with fever and facial swelling. It has a good prognosis with appropriate treatment. It may also prove to be a sensitive clinical indicator of the presence of melioidosis within a particular geographic area.     

Bacteraemic melioidosis pneumonia: impact on outcome, clinical and radiological features

OBJECTIVES: Melioidosis is an endemic disease in South-east (SE) Asia and bacteraemia in melioidosis is associated with high mortality. We describe some clinical and radiological features of bacteraemic pneumonia due to Burkholderia pseudomallei as well as a comparison with bacteraemic patients without pneumonia. METHODS: Patients with positive blood cultures for B. pseudomallei from October 1997 to November 2001 were included. Patients were grouped as 'Pneumonia' and 'Non-pneumonia' according to clinical and radiological features. RESULTS: Eighteen (60%) out of total 30 patients were in the pneumonia group. There was no significant difference in age, WBC count, platelet counts and bilirubin levels between the groups. However the 'Pneumonia' group had higher incidences of hyponatraemia, acidosis, diabetes with poor control, renal impairment and shorter length of stay. Twelve (66%) of 18 patients in the pneumonia group required ICU admission compared to none in the non-pneumonia group; all required mechanical ventilation. Only 13/30 (43%) patients had initial empiric antibiotic therapy that is appropriate for melioidosis. The pneumonia group also had significantly higher mortality (13/18, 72%) rate than the non-pneumonia group (3/12, 25%, P=0.03). Chest radiographs were non-specific. 7/18 (38%) had unilobar involvement of the lung, mostly left sided; the rest had multilobar or bilateral involvement. Six (33%) had pleural effusion. No patient had cavitary lung disease. Visceral abscesses (spleen, liver and prostate) were also common in ultrasound and CT scans in both groups. CONCLUSION: (1) Bacteraemic melioidosis with pneumonia carries high mortality with most patients dying early. (2) Radiological features of melioidosis pneumonia are non-specific. (3) Clinicians who treat patients from SE Asia need to be aware of this condition to institute early and appropriate antibiotic therapy.     

Molecular characterization of clinical Burkholderia pseudomallei isolates from India

Multilocus sequence typing of seven isolates of Burkholderia pseudomallei from India showed considerable diversity, with six different sequence types. Possible dissemination of melioidosis by historical trading routes is supported by links to strains from Southeast Asia, China, and Africa and the presence of the Burkholderia mallei allele of the bimA gene.     

Sporadic and Outbreak Cases of Melioidosis in Southern Taiwan: Clinical Features and Antimicrobial Susceptibility

Abstract Background:   Melioidosis has been well known to be endemic in Thailand and Northern Australia, and was reported sporadically in Taiwan before 2005. Methods:   We retrospectively analyzed 58 patients with melioidosis in southern Taiwan from 2000 to 2005, including 40 clustered and 18 sporadic cases, for clinical characteristics and antimicrobial susceptibility. Results:   Fifty-one (88%) cases were found during the rainy season, and there was a significant correlation between the average monthly rainfalls and the case number (r = 0.37; p = 0.001). Diabetes mellitus was the most common underlying disease (35 cases, 60%). The majority (52 cases, 90%) had never traveled abroad before illness, indicating indigenous acquisition of Burkholderia pseudomallei. In comparison, clustered cases were older, less often had underlying diabetes mellitus and had a shorter duration of clinical symptoms before admission than sporadic cases. Acute form of melioidosis predominated, and shock at admission was independently associated with a grave prognosis. Overall, 22% of 58 patients died in hospitals. Ceftazidime, imipenem, meropenem, amoxicillin/clavulanic acid, co-trimoxazole, and doxycycline, as previously recommended, were the potentially therapeutic choices. The role of piperacillin/ tazobactam for melioidosis remains undefined. Conclusions:   Melioidosis can occur sporadically or in a cluster in diabetic patients during rainy seasons in Taiwan.     

Melioidosis: an important cause of pneumonia in residents of and travellers returned from endemic regions.

Melioidosis is endemic in South East Asia, Asia and northern Australia. Infection usually follows percutaneous inoculation or inhalation of the causative bacterium, Burkholderia pseudomallei, which is present in soil and surface water in the endemic region. While 20-36% of melioidosis cases have no evident predisposing risk factor, the vast majority of fatal cases have an identified risk factor, the most important of which are diabetes, alcoholism and chronic renal disease. Half of all cases present with pneumonia, but there is great clinical diversity, from localised skin ulcers or abscesses without systemic illness to fulminant septic shock with multiple abscesses in the lungs, liver, spleen and kidneys. At least 10% of cases present with a chronic respiratory illness (sick > 2 months) mimicking tuberculosis and often with upper lobe infiltrates and/or cavities on chest radiography. As with tuberculosis, latency with reactivation decades after infection can also occur, although this is rare. Confirmation of diagnosis is by culture of B. pseudomallei from blood, sputum, throat swab or other samples. Microbiology laboratories need to be informed of the possibility of melioidosis, as those not familiar with it can misidentify the organism. Antibiotic therapy is initial intensive therapy with i.v. ceftazidime or meropenem or imipenem +/- cotrimoxazole for > or = 10 days, followed by eradication therapy with cotrimoxazole +/- doxycycline +/- chloramphenicol (first 4 weeks only) for > or = 3 months. Melioidosis has been increasingly recognised in returning travellers in Europe and recently melioidosis and colonisation with B. pseudomallei have been documented in cystic fibrosis patients visiting or resident in endemic areas.     

Ceftazidime monotherapy for pulmonary melioidosis in a traveler returning from Thailand.

A patient with deteriorating pulmonary melioidosis rapidly recovered after treatment with ceftazidime. To prevent possible relapses, an oral maintenance regimen of amoxicillin and clavulanic acid was prescribed for a period of three months. Melioidosis is caused by Pseudomonas pseudomallei. It is an insidious disease because of its variable clinical presentation, possible long-term asymptomatic carriage, broad-spectrum resistance to first-line antibiotics, and high mortality rate. As in our patient, the diagnosis should be particularly considered when there is reduced immunologic resistance and previous exposure in endemic areas, such as Southeast Asia.     

Short report: application of a polymerase chain reaction to detect Burkholderia pseudomallei in clinical specimens from patients with suspected melioidosis

The diagnostic potential of a Burkholderia pseudomallei type three secretion system (TTS1) polymerase chain reaction (PCR) was examined on clinical specimens from 27 patients with sepsis in the Northern Territory of Australia, a region endemic for melioidosis. The TTS1 PCR was conducted on DNA extracted from a range of clinical specimens (blood, sputum, urine, joint, pericardial and pleural fluid, and swabs from skin lesions, throat, nose, and rectum). The PCR sensitivity in culture-positive clinical specimens from the nine confirmed patients with melioidosis was 65% and the specificity was 100%, with no PCR-positive results in specimens from 18 patients without melioidosis. The PCR based on the B. pseudomallei TTS1 has the potential to substantially improve the timeliness of diagnosis of melioidosis.     

Melioidosis presenting as urinary tract infection in a previously healthy tourist

Melioidosis is a tropical disease caused by Burkholderia pseudomallei, which is common in southeast Asia and Australia, but which is rarely diagnosed in Scandinavia. An increasing number of cases are being reported among tourists to infected areas. We report the first Finnish case of melioidosis, which presented as urinary tract infection in a previously healthy male tourist.     

Melioidosis epidemiology and risk factors from a prospective whole-population study in northern Australia

OBJECTIVES: The aims of this study were to describe the epidemiology of melioidosis in tropical northern Australia and to assess the importance of defined risk factors. METHODS: The data were taken from a 14-year prospective study of 364 cases of melioidosis in the 'Top End' of the Northern Territory. A whole-population logistic regression model was used to estimate the crude and adjusted relative risk (RR) for the defined risk factors. RESULTS: The mean age of the study population was 46.8 years, 264 (72.5%) were male, 178 (49%) were aboriginal Australians and 59 (16.2%) died from melioidosis. Average annual incidence was 19.6 cases per 100 000 population, with an estimated rate of 260 cases per 100,000 diabetics per year. Using a whole-population logistic regression model, the estimated crude and adjusted RR [95% confidence intervals (CI)] for melioidosis were 6.3 (5.1-7.8) and 4.0 (3.2-5.1) for those aged > or = 45 years, 2.3 (1.8-2.9) and 2.4 (1.9-3.0) for males, 2.9 (2.3-3.5) and 3.0 (2.3-4.0) for aboriginal Australians, 21.2 (17.1-26.3) and 13.1 (9.4-18.1) for diabetics, 2.7 (2.2-3.4) and 2.1 (1.6-2.6) for those with excess alcohol consumption, 6.8 (5.4-8.6) and 4.3 (3.4-5.5) for chronic lung disease and 6.7 (4.7-9.6) and 3.2 (2.2-4.8) for chronic renal disease, respectively. CONCLUSIONS: Diabetes, excess alcohol intake, chronic renal disease and chronic lung disease are each independent risk factors for melioidosis. In tropical northern Australia, male sex, aboriginal ethnicity and age of > or = 45 years are also independent predictors for melioidosis. Impaired polymorph function may be critical in the predisposition to melioidosis.