Case history
Case history #1
A 30-year-old diabetic rice farmer from rural Cambodia presents to a small regional hospital with 2 weeks of fevers, night sweats, increasing dyspnoea, and cough with slightly purulent sputum. On examination he has a temperature of 39.3°C, heart rate of 104 bpm, and respiratory rate of 28 breaths per minute with oxygen saturation on room air of 92%. BP is 90/60 mmHg, increasing to only 95/60 mmHg after 2 litres of intravenous normal saline. Respiratory examination shows normal percussion note but generalised inspiratory crepitations and wheeze. Chest x-ray shows an area of patchy consolidation in the right upper lobe and abdominal ultrasound shows features suggestive of several liver abscesses. He is commenced on intravenous ceftriaxone but progressively deteriorates over 12 hours. Antibiotic treatment is changed to intravenous ceftazidime. Despite this, his condition worsens. At 24 hours a repeat chest x-ray shows progression of pneumonia to involve all of the right lung, and infiltrates can now also be seen in the left lung. His heart rate has increased to 120 beats per minute, blood pressure decreased to 80/50 mmHg, and respiratory rate is 32 breaths per minute with oxygen saturation 88% despite oxygen therapy. The patient develops progressive pneumonia and septic shock 36 hours after admission, and is intubated and transferred to intensive care. Blood cultures taken from the patient on admission are positive for Burkholderia pseudomallei.
Case history #2
A 24-year-old male returns to the UK from a backpacking holiday in Australia, which included a camping trip to Kakadu National Park in the Northern Territory. On the flight home he developed fever and abdominal pain. He also noted dysuria and mild diarrhoea. On presentation to the emergency department the next day his symptoms have progressed, his temperature is 39.2°C, and on examination he has tenderness in the lower abdomen with dull percussion suggesting urinary retention. A urinary catheter is inserted, draining 800 mL of dark urine. He is commenced on intravenous ampicillin, gentamicin, and metronidazole. The next day, he remains febrile and unwell and the microbiology laboratory report growth of a gram-negative bacillus from both his blood cultures and urine. Initial automated tests do not identify the organism species, but the clinical microbiologist had previously worked in Thailand and Laos and recognises the appearance of B pseudomallei. This is quickly confirmed by standard biochemical testing. Antibiotic treatment is changed to intravenous ceftazidime and oral trimethoprim/sulfamethoxazole. Computed tomography scan of the abdomen and pelvis shows a large prostatic abscess, which is drained the same day per rectum. The patient continues standard therapy for melioidosis and makes a full recovery.
Other presentations
Patients can present with single non-healing skin ulcers/abscesses without systemic sepsis.[9] This is more common in children and those with no risk factors for melioidosis.[10] Parotitis, usually unilateral, is one of the most common presentations in children in Southeast Asia,[11][12] but is very rare in Australia.[7]
Septic arthritis and/or osteomyelitis can rarely be the primary presentation of melioidosis, but are more common as secondary manifestations that appear clinically a week or more into therapy for melioidosis, presenting as pneumonia or other sepsis.[13]A case of a patient presenting with spondylodiscitis has been reported.[14]
CNS melioidosis, while rare, may present as osteomyelitis or scalp/extra-axial abscess.[15] A case of a spinal epidural abscess has also been reported.[16] Melioidosis encephalomyelitis is rare and mostly restricted to infection in northern Australia and seen relatively more commonly in children.[10][17][18] Presentation is with fevers, often headaches with/without altered conscious state, and cranial nerve palsies (e.g., lower motor neuron VII and VIII nerve), usually with some peripheral motor weakness.[19] Occasionally flaccid paralysis with/without urinary retention occurs from myelitis without the features of brainstem encephalitis.[10] Bacteraemic spread can result in brain abscesses and this is not restricted to Australia.[20]
Mycotic pseudo-aneurysms of usually atherosclerotic major arteries (most commonly the abdominal aorta) are a rare but life-threatening primary or secondary clinical manifestation of melioidosis that requires urgent referral to a vascular surgeon.[21]
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