Clinical Definitions of Melioidosis

Clinical definitions of melioidosis and inhalation-acquired melioidosis (Burkholderia pseudomallei infection) are described together with the evidence used to develop these definitions. Such definitions support accurate public health reporting, preparedness planning for deliberate B. pseudomallei release, design of experimental models, and categorization of naturally acquired melioidosis.     

Emergence of Melioidosis in Indonesia

Melioidosis is known to be highly endemic in parts of southeast Asia and northern Australia; however, cases are rarely reported in Indonesia. Here we report three cases of melioidosis in Makassar, South Sulawesi, Indonesia occurring between 2013 and 2014. Two patients died and the other was lost to follow-up. Burkholderia pseudomallei isolates from all three cases were identified by the VITEK2 Compact installed in the hospital in 2012. None of the three patients reported received antimicrobials recommended for melioidosis because of the delayed recognition of the organism. We reviewed the literature and found only seven reports of melioidosis in Indonesia. Five were reported before 1960. We suggest that melioidosis is endemic throughout Indonesia but currently under-recognized. Training on how to identify B. pseudomallei accurately and safely in all available microbiological facilities should be provided, and consideration should be given to making melioidosis a notifiable disease in Indonesia.     

Using BOX-PCR to exclude a clonal outbreak of melioidosis

Background  

Although melioidosis in endemic regions is usually caused by a diverse range of Burkholderia pseudomallei strains, clonal outbreaks from contaminated potable water have been described. Furthermore B. pseudomallei is classified as a CDC Group B bioterrorism agent. Ribotyping, pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) have been used to identify genetically related B. pseudomallei isolates, but they are time consuming and technically challenging for many laboratories.     

Melioidosis as a Consequence of Sporting Activity

In the tropical city of Darwin, Northern Territory, Australia, dry season soil sampling cultured Burkholderia pseudomallei from 7 (70%) of 10 sports fields. However, during the 23 years of the Darwin Prospective Melioidosis Study, only 5 (0.6%) of 785 melioidosis cases have been attributed to infection from sports fields. In one soccer player with cutaneous melioidosis, B. pseudomallei cultured from the player was identical by multilocus sequence typing and multilocus variable-number tandem repeat analysis with an isolate recovered from soil at the location on the sports field where he was injured. Melioidosis is uncommon in otherwise healthy sports persons in melioidosis-endemic regions but still needs consideration in persons with abrasion injuries that involve contact with soil.Athletes can be infected by pathogens through inoculation events caused by cuts and abrasions resulting from sporting activities.¹ A notable example is the methicillin-resistant Staphylococcus aureus outbreak in a professional American football team that was associated with turf-abrasion inoculation.² With the globalization of sporting competitions, the rate of returning athletes with diseases endemic to tropical regions is expected to increase, such as occurred with the Eco-challenge 2000 event in Malaysian Borneo, where leptospirosis developed in > 80 of the endurance athletes after contact with contaminated water and soil.^3,4 Melioidosis is another disease that is endemic in tropical regions, potentially placing athletes at risk from inoculation events through broken skin and contact with contaminated soil or surface water.^5,6In the early 1970s, Burkholderia pseudomallei, the causative bacterium of melioidosis was found in surface water samples of five sports fields in Singapore⁷ after a potential sporting connection in two of ten cases described from neighboring Malaysia.⁸ In Darwin in northern Australia, B. pseudomallei levels in the upper soil layers increase during the wet season (October–April), and B. pseudomallei is often cultured from surface water.⁹ The first use of molecular genotyping to link clinical isolates of B. pseudomallei to epidemiologically related environmental strains was published in 1994 and used ribotyping.¹⁰ However, ribotyping has limited specificity in its ability to discriminate between closely related strains of B. pseudomallei. Subsequently, pulsed-field gel electrophoresis was shown to be superior to ribotyping and was used to link two separate clonal clusters of melioidosis in northern Australia to contamination of the community water supplies with B. pseudomallei.^11,12 Multilocus sequence typing (MLST) has more recently become the global standard for epidemiologic investigations of melioidosis, with > 1,000 B. pseudomallei sequence types (STs) identified worldwide.¹³Early in the 2005 Darwin dry season, a soccer player had chronic cutaneous melioidosis of the lower leg after a grass-abrasion incident 2.5 months earlier on a water-logged Darwin soccer field. Burkholderia pseudomallei was cultured from the leg ulcer (isolate MSHR2080) and also from pus from incision and drainage of an ipsilateral inguinal lymph node abscess (MSHR2078). The patient made a full recovery after therapy for two weeks with intravenous ceftazidime plus oral trimethoprim/sulfamethoxazole, followed by three additional months of oral trimethoprim/sulfamethoxazole. Environmental sampling was undertaken as a response to the incident and nine B. pseudomallei isolates were cultured from soil samples taken at various locations on the soccer field, including one isolate (MSHR2188) from the location where the patient identified that the abrasion incident had occurred.Multilocus sequence typing was performed on the strains from this study, and patient strains MSHR2078 and MSHR2080 were typed as ST36. ST36 was also found in four of nine soccer field soil samples, including MSHR2188, and the remaining 5 isolates typed as ST144. ST36 has been found in clinical and environmental samples elsewhere in the Northern Territory. Therefore, to obtain greater genotypic resolution of the soccer field and clinical isolates, we performed multilocus variable-number tandem repeat analysis (MLVA) on the six ST36 isolates by using four-locus MLVA (MLVA-4) as described.¹⁴ Multilocus variable-number tandem repeat analysis can discriminate within a single MLST ST and thus can help further establish the relatedness of isolates that have temporal and spatial proximity to each other.¹⁵ MSHR2078 and MSHR2080 strains from the patient were identical at all four MLVA loci to MSHR2188 retrieved from soil at the location of the abrasion incident. In contrast, the three ST36 environmental isolates from different locations of the same field contained 1–3 MLVA locus mismatches when compared with MSHRs 2078, 2080 and 2188. The 100% MLST and MLVA match between clinical and environmental isolates supports the field soil being the source of the soccer player''s infection.The Darwin Prospective Melioidosis Study began in October 1989, and in the 23 years until October 2012, there have been 785 culture-confirmed cases of melioidosis identified at Royal Darwin Hospital. We previously documented that in 22% of cases there was a specific exposure scenario that was considered the likely infecting event, with most events being abrasion or laceration inoculations.¹⁶ Despite this finding, during 23 years there have been only 5 (0.6%) of 785 cases (including the one described in this report) where the documented suspected infecting event involved an injury on a Darwin sports field: three from soccer, one from rugby, and one from Australian rules football.Field sports are especially popular during the Darwin dry season, when there is less surface water and B. pseudomallei is less abundant at the soil surface.⁹ Nevertheless, irrigation of sports fields during the dry season is considered likely to increase survival of B. pseudomallei in upper soil layers. We therefore investigated the prevalence of B pseudomallei at ten Darwin grassed sports fields during the dry season of 2010, and collected ten soil samples per field. Using culture,¹⁷ we detected B. pseudomallei at 7 (70%) of 10 sports fields. This prevalence was higher than our previous finding of 27% (38 of 141) B. pseudomallei positive sites (environmentally disturbed and undisturbed sites) in the 2006 dry season (P = 0.008, by two-tailed Fisher''s exact test), and with 16% (16 of 100) positive sports field soil samples overall, the prevalence was similar to the prevalence we found in soil samples from irrigated gardens (17%, 11 of 65).⁹ The mean pH of each positive field was within the optimal pH range for B. pseudomallei survival and growth (5.0–6.0)¹⁸ and electrical conductivity measures of salt content were low, which is consistent with previous environmental studies of conditions favorable for B. pseudomallei.¹⁷Although there may be some under-ascertainment of inoculating event histories, we have identified only five cases of sports field-related melioidosis in Darwin in over 20 years, despite the high incidence of melioidosis in Darwin, the high prevalence of B. pseudomallei in sports field soil, and the large numbers of adults and children partaking in organized sports. This low number reflects the opportunistic nature of melioidosis, a disease that predominantly affects those with defined medical risk factors such as diabetes and hazardous alcohol use, and where severe disease is relatively uncommon in healthy persons.¹⁶ Although cutaneous melioidosis without disseminated disease occurs in healthy persons,¹⁹ most melioidosis cases diagnosed in the United States and Europe are in returned travelers or residents from melioidosis-endemic regions who have recognized risk factors such as diabetes and cystic fibrosis.²⁰ The rarity of severe melioidosis in those without risk factors contrasts with leptospirosis, where severe disease is well recognized to occur in exposed healthy travelers participating in outdoor activities such as sports.^3,4 Nevertheless fatal co-infection with both melioidosis and leptospirosis has also been recently described.²¹In conclusion, melioidosis is uncommon in otherwise healthy sports persons in melioidosis-endemic regions. However, this disease needs to be suspected in persons with abrasion injuries that involve contact with soil.     

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.     

The Humoral Immune Response in Melioidosis Patients during Therapy

Background: This study was undertaken to identify and quantify the class and subclass antibody responses to the culture filtrate antigen (CFA) of Burkholderia pseudomallei in melioidosis patients under long-term maintenance or eradication therapy. Materials and Methods: Sequential sera samples from seven melioidosis patients collected between January 1992 and April 1998 were analyzed for immunoglobulin (Ig) types and IgG isotypes by ELISA using B. pseudomallei CFA. Results: Melioidosis patients generated a strong IgG, IgA and IgM response to the CFA of B. pseudomallei throughout the infection and IgG1 and IgG2 were the predominant IgG istotypes produced. Although high levels of these antibodies were detected in all the seven patients, the IgG, IgG1 and IgG2 antibodies showed a consistent response and good correlation with the clinical history in all cases. Conclusion: This study suggests that monitoring IgG antibody or IgG1 or IgG2 isotype antibody levels to CFA in patients under maintenance or eradication antibiotic therapy may be useful as a tool to detect the status of infection and as a guideline to determine the duration of maintenance antimicrobial therapy. Received: February 4, 2002 · Revision accepted: October 6, 2002 C. Vasu (corresponding author)     

Increasing Incidence of Human Melioidosis in Northeast Thailand

Melioidosis is a serious community-acquired infectious disease caused by the Gram-negative environmental bacterium Burkholderia pseudomallei. A prospective cohort study identified 2,243 patients admitted to Sappasithiprasong Hospital in northeast Thailand with culture-confirmed melioidosis between 1997 and 2006. These data were used to calculate an average incidence rate for the province of 12.7 cases of melioidosis per 100,000 people per year. Incidence increased incrementally from 8.0 (95% confidence interval [CI] = 7.2–10.0) in 2000 to 21.3 (95% CI = 19.2–23.6) in 2006 (P < 0.001; χ² test for trend). Male sex, age ≥ 45 years, and either known or undiagnosed diabetes were independent risk factors for melioidosis. The average mortality rate from melioidosis over the study period was 42.6%. The minimum estimated population mortality rate from melioidosis in 2006 was 8.63 per 100,000 people (95% CI = 7.33–10.11), the third most common cause of death from infectious diseases in northeast Thailand after human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and tuberculosis.     

A Case of Imported Melioidosis Presenting as Prostatitis

We report a case of melioidosis in a previously healthy Belgian man. He presented with septicemia and prostatic abscesses 1 week after a trip to Vietnam. Burkholderia pseudomallei was isolated from multiple hemocultures. He was treated successfully with intravenous ceftazidime and trimethoprim-sulfamethoxazole, followed by a per-oral maintenance therapy of amoxicillin-clavulanate with supplementary amoxicillin. There was no need for surgical drainage. This is the second reported case of melioidosis in Belgium. Received: July 30, 2001 · Revision accepted: April 23, 2002 A. M. Heyse (corresponding author)     

Case Report: Incidental Splenic Granuloma due to Burkholderia pseudomallei: A Case of Asymptomatic Latent Melioidosis?

We report a rare case of an asymptomatic latent melioidosis lesion in a posttraumatic splenectomy specimen from a diabetic patient. The 2-cm yellowish, lobulated lesion was found in the splenic parenchyma well away from the traumatized areas. Microscopically, it consisted of a central area of necrosis and exudate surrounded by macrophages, epithelioid cells, lymphocytes, and occasional multinucleated giant cells. Burkholderia bacilli were detected by a novel in situ hybridization (ISH) assay, and confirmed by polymerase chain reaction and sequencing to be Burkholderia pseudomallei. As melioidosis was not suspected initially, bacterial culture was not done but electron microscopy showed morphologically viable and dividing bacilli in the lesion. Moreover, the surgical wound became infected with B. pseudomallei several days post-surgery. After treatment with ceftazidime and trimethoprim/sulfamethoxazole, the wound infection cleared. We believe this could be a unique case of asymptomatic latent melioidosis in the spleen. In endemic countries, chronic granulomas should be investigated for B. pseudomallei infection, and if available, ISH may be helpful for diagnosis.     

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.     

Prevalence of Melioidosis in Patients with Suspected Pulmonary Tuberculosis and Sputum Smear Negative for Acid-Fast Bacilli in Northeast Thailand

The clinical and radiological features of pulmonary melioidosis can mimic tuberculosis. We prospectively evaluated 118 patients with suspected pulmonary tuberculosis who were acid-fast bacilli (AFB) smear negative at Udon Thani Hospital, northeast Thailand. Culture of residual sputum from AFB testing was positive for Burkholderia pseudomallei in three patients (2.5%; 95% confidence interval [CI] 0.5–7.3%). We propose that in melioidosis-endemic areas, residual sputum from AFB testing should be routinely cultured for B. pseudomallei.Melioidosis is a serious infectious disease caused by the Tier 1 Select Agent and Gram-negative bacillus, Burkholderia pseudomallei.¹ Naturally acquired melioidosis is highly endemic in northeast Thailand where it is the third most common cause of death caused by infectious diseases after human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and tuberculosis,² and in northern Australia where it is the commonest cause of fatal community-acquired bacteremic pneumonia.³ Melioidosis is also increasingly reported from many countries across Asia, regions of South America, various Pacific and Indian Ocean islands, and some countries in Africa including Nigeria, Gambia, Kenya, and Uganda.¹ Death from melioidosis reaches 80% in those who are not treated with effective antimicrobial drugs.⁴Melioidosis can manifest with a variety of clinical presentations including sepsis, pneumonia, arthritis, and internal organ abscesses, and has been termed “the great mimicker” because it can be confused with a range of diseases. The most notable example is tuberculosis, with an estimated 10% of melioidosis patients presenting with chronic respiratory symptoms and chest radiography mimicking pulmonary tuberculosis.⁵ In reported cases, failure of clinical improvement after the administration of anti-tuberculosis drugs led to bacteriological culture of sputum, broncho-alveolar lavage, or blood and the detection of B. pseudomallei.^6–8 Although it is clear that melioidosis can mimic clinical features of tuberculosis, patients presenting with suspected tuberculosis in Thailand where melioidosis is highly endemic are not systematically screened for melioidosis. Here, we evaluated the use of culturing sputum samples taken from individuals in Thailand with suspected tuberculosis that were smear negative for acid-fast bacilli (AFB) to detect B. pseudomallei.     

Fatal Melioidosis in Goats in Bangkok,Thailand

Bangkok, Thailand, is a city considered to be at low risk for melioidosis. We describe 10 goats that died of melioidosis in Bangkok. Half of them were born and reared in the city. Multilocus sequence typing ruled out an outbreak. This finding challenges the assumption that melioidosis is rarely acquired in central Thailand.Melioidosis, an often fatal infectious disease for humans and animals, is caused by the Gram-negative bacillus and biothreat select agent Burkholderia pseudomallei.¹ This organism is present in soil and water in melioidosis-endemic regions of the world, including much of Asia, northern Australia, regions of South America, some countries in Africa, and various Pacific and Indian Ocean islands.¹ Most infections in humans and animals occur after skin inoculation, inhalation, or ingestion of the organism from the environment. A wide range of animal species are susceptible to melioidosis, including sheep, goats, swine, horses, cats, dogs, and non-human primates.²We recently described the first report of culture-confirmed melioidosis in animals in Thailand, in which goats were the most frequently affected species.³ The regions where animal melioidosis were reported mapped to those areas where melioidosis is endemic in humans, including northeastern, eastern, southern, and western Thailand. To our knowledge, animal melioidosis has not been reported from central Thailand, and melioidosis is not considered to be endemic in humans in this area.^1,4 Here, we describe 10 goats that died of melioidosis in Bangkok in central Thailand.Study animals underwent necropsy as part of a routine service at the Veterinary Diagnostic Center, Mahanakorn University of Technology, Nong Chok District, Bangkok, Thailand. Organs with gross pathologic lesions were cultured on bovine blood agar and MacConkey agar. Presumptive B. pseudomallei colonies were confirmed by using conventional biochemical tests, multiplex polymerase chain reaction,⁵ and latex agglutination tests.⁶ A total of 72 goats and 367 other animals were necropsied during 2006–2012. Ten goats (14%) had at least one specimen that was culture positive for B. pseudomallei, and all other animals were culture negative for this species.The ten goats were from six different farms (range = 1–4 goats/farm) located in two districts in Bangkok (Nong Chok and Khlong Sam Wa). The median age of affected goats was three years (range = 2–4 years), and nine (90%) were female. Common symptoms before death were pneumonia (n = 9), weakness (n = 4), anorexia (n = 2), neurologic symptoms (n = 2), and mastitis (n = 2). All cases had more than one organ involved, and multiple abscesses in the lung, liver, and spleen were common (

An Improved Selective Culture Medium Enhances the Isolation of Burkholderia pseudomallei from Contaminated Specimens

Burkholderia pseudomallei is a Gram-negative environmental bacterium found in tropical climates that causes melioidosis. Culture remains the diagnostic gold standard, but isolation of B. pseudomallei from heavily contaminated sites, such as fecal specimens, can be difficult. We recently reported that B. pseudomallei is capable of infecting the gastrointestinal tract of mice and suggested that the same may be true in humans. Thus, there is a strong need for new culture techniques to allow for efficient detection of B. pseudomallei in fecal and other specimens. We found that the addition of norfloxacin, ampicillin, and polymyxin B to Ashdown''s medium (NAP-A) resulted in increased specificity without affecting the growth of 25 B. pseudomallei strains. Furthermore, recovery of B. pseudomallei from human clinical specimens was not affected by the three additional antibiotics. Therefore, we conclude that NAP-A medium provides a new tool for more sensitive isolation of B. pseudomallei from heavily contaminated sites.     

Ribotyping of Burkholderia pseudomallei from clinical and soil isolates in Thailand

Burkholderia pseudomallei is a soil saprophyte that causes melioidosis in humans and animals. Restriction fragment length polymorphism of the ribosomal DNA regions (ribotyping) were analyzed in 577 isolates comprising 371 clinical and 206 soil isolates collected throughout Thailand in 1997. A total of 77 distinct ribotype patterns consisting of 2–9 bands with sizes ranging from 2.8 to >23 kb were found. Twelve major ribotypes were identified of which types 3, 8 and 23 were commonly found (278/577, 48.2%) in both clinical (217/371, 58.5%) and environmental isolates (61/206, 29.6%). Three unique environmental types were found whereas a unique clinical type was not observed. Even though ribotypes show high heterogeneity in the rDNA region, the unique environmental patterns were clearly different from the clinical patterns as clearly seen by UPGMA dendrogram. Moreover, the three major types (types 3, 8 and 23) were discovered in nearly half of B. pseudomallei isolates. Subtyping of these major ribotypes in correlation with clinical profiles may help researchers to identify the virulence factor of the organism.     

Melioidosis—an unusual cause of septic arthritis

Melioidosis is an infection caused by Burkholderia pseudomallei. It is an important human pathogen in the tropical area. The clinical manifestations are protean with multisystem involvement. Septic arthritis and prostatic abscess are rare but well-recognized forms of the disease. Herein we report a case of melioidosis presenting with a rare combination of septic arthritis, prostatic abscess, and septicemia.     

Alteration of the Phenotypic and Pathogenic Patterns of Burkholderia pseudomallei that Persist in a Soil Environment

Melioidosis is caused by the soil-borne pathogen Burkholderia pseudomallei. To investigate whether the distinct phenotypic and virulent characteristics result from environmental adaptations in the soil or from the host body, two pairs of isogenic strains were generated by passages in soil or mice. After cultivation in soil, the levels of 3-hydroxytetradecanoic acid, biofilm formation, flagellar expression, and ultrastructure were altered in the bacteria. Uniformly fatal melioidosis developed as a result of infection with mouse-derived strains; however, the survival rates of mice infected with soil-derived strains prolonged. After primary infection or reinfection with soil-derived strains, the mice developed a low degree of bacterial hepatitis and bacterial colonization in the liver and bone marrow compared with mice that were infected with isogenic or heterogenic mouse-derived strains. We suggest that specific phenotypic and pathogenic patterns can be induced through infection with B. pseudomallei that has been cultured in different (soil versus mouse) environments.     

海南1例感染类鼻疽伯克霍尔德菌的溯源调查

目的 对海南1例类鼻疽患者进行感染溯源调查,为类鼻疽防控提供科学依据。方法 采集患者住所周边环境中的泥土、水等样品并进行类鼻疽病原菌分离。通过细菌学试验、16S rDNA测序、特异诊断PCR等方法对疑似菌株进一步鉴定。通过脉冲场凝胶电泳(PFGE)、多位点序列分型(MLST)、多位点可变数串联重复序列分析(MLVA_4)等技术比较并确定环境分离菌株与临床菌株的同源性。结果 采集的58份环境样品中,自患者及邻居家水井水中共分离出3株类鼻疽伯克霍尔德菌(简称类鼻疽伯克菌)。PFGE、MLST、MLVA等分子分型结果证实,1株自患者家井水中分离的类鼻疽伯克菌与患者临床分离株同源。结论 患者及其邻居家水井均被类鼻疽伯克菌污染,水井水很可能是该患者感染类鼻疽病的感染源。     

Case cluster shifting and contaminant source as determinants of melioidosis in Taiwan

Objectives To assess the geographical distribution of melioidosis contamination sources and the association between the location of melioidosis cases and positive sampling sites for Burkholderia pseudomallei in Taiwan. Methods Data on the location of melioidosis cases from 2002 to 2011 were combined with the geographical distribution of B. pseudomallei as indicated by the detection of specific flagella gene products measured from 2005 to 2011. Temporal and spatial analyses were used to determine the incidence, cluster shifts and associations between the two datasets. Results Melioidosis cases clustered in two ‘hot‐spot’ areas with incidence rates that were significantly higher than in neighbouring towns. The incidence rates in the northern area gradually decreased, while the rates in the southern area increased and were temporally associated with the appearance of B. pseudomallei‐specific flagella genes in water samples. Conclusions Melioidosis hot‐spot areas were present in Taiwan. Water contaminated with B. pseudomallei serves as a potential transmission vehicle and is correlated with an increase in melioidosis cases; this correlation was stronger than that for B. pseudomallei‐contaminated soil.     

Septicemic melioidosis: a case report and literature review

This report was about a 22-year-old male patient who died from acute and severe septicemic melioidosis. He was initially misdiagnosed as having pneumonia in a local hospital in Hainan but transferred to Guangzhou Red Cross Hospital after ineffective treatment and detection of Burkholderia pseudomallei in his blood sample. Unfortunately, right diagnosis and antibiotic treatment of melioidosis had been delayed so that his condition deteriorated rapidly out of control. The victim’s death highlights the importance of early diagnosis and effective antibiotic treatment of septicemic melioidosis in areas where this disease is prevalent.