Summary

Background
Melioidosis,also called Whitmore's disease, is an infectious disease caused by a gramnegative bacterium, Burkholderia pseudomallei, found in soil and water. It exists in acute and
chronic forms.
This organism is present in the environment in a defined geographic distribution including
much of South-east Asia and Northern Australia, where infection is thought to be acquired
after bacterial inoculation, ingestion or inhalation.1,2
The organism is a motile gram-negative, oxidase positive bacterium that produces
a neutral- alkaline reaction on triple sugar iron, grows at 420 C and is colistin resistant.

Case presentation
57 year old Retired army serviceman, presented to the Emergency Department with
complains of fever, low back pain, reduced apetite and fatigubality for past 15 days.
3 months ago the patient was apparently normal. He had fever associated with
difficulty in passing urine,constipation and swelling of the lower limbs.
He was diagnosed with BPH in a Hospital and treated for UTI at a small clinic. He did
not improve and was evaluated at a tertiary hospital. Trans Rectal USG showed
prostatic abcess. Prostatic biopsy was taken and Pus culture showed growth of
Burkholdia Cepacia, for which he was started on broad spectrum antibiotics
(Amikacin).
After he recovered in the hospital, he was discharged with oral Antibiotics (Bactrim
DS) duration of therapy???
At home he developed recurrence of the previous symptoms WHEN ? WAS IT
AFTER COMPLETION OF DRUG THERAPY with fever, B/L lower limb swelling And
had productive cough.
He was again taken to the Hospital where He was referred to a Pulmonologist.
HRCT CHEST was done, to rule out Pneumonia or recurrence of PTB, which
showed Cavitating Consolidation In Left Upper Lobe And Lower Lobe With Ground
Glass Attenuation. WHAT WAS HE TREATED WITH? for how long?
He was was then referred to Our hospital for further management.
On physical examination patient was tachycardic, mildly febrile and Dehydrated.His
body temperature was 100 F, blood pressure 110/60mm Hg, respiratory rate 26/min,
and heart rate 118/min. No Respiratory, cardiovascular or neurological abnormality
was noted. On local examination, Bilateral pitting Pedal oedema was elicited.
His Random Blood Glucose was 533mg/dL, ABG results showed Metabolic Acidosis.
He was then treated with suspicion of DKA and was admitted into the ICU.

He was managed in the ICU with Insulin infusion and Slow IV fluids. On further
evaluation Patient was found to have Chronic Anemia and Leukocytosis.
Cardiology Opinion was taken, ECHO done which showed Severe LV
dysfunction(27%).
Broncho Alveolar Lavage done by the Pulmonologist showed Gram Negative
Bacteria Growth.
Infectious Disease Opinion was then taken and Blood was sent for MALDI-TOF
(Matrix Assisted Laser Desorption/Ionization Time-of-Flight), which was Positive for
Burkholdia Pseudomallei.
Meliodosis was diagnosed.
Co morbidities
Old PTB diagnosed 7 years ago took ATT for 6 months

Recurrent Bronchitis.

BPH with bladder outlet obstruction.

Type 2 DM 15 years on treatment

Personal history
Smoker and regular alcohol intake for more than 10 Years.

Differential diagnosis
Treatment
Patient was then treated with 14 days course of Oral Ceftazidime and then switched over to
Oral Ciprofloxacin and Doxycycline at Discharge

Outcome and follow-up

Patient improved clinically following the treatment with Ceftazidime. His EF improved
substantially.

Discussion
B. pseudomallei is an environmental inhabitant and is widely disseminated in soil, water,
paddy fields, etc. It is geographically restricted to tropical and subtropical and Southeast
Asian countries and some areas of Australia.
In India, quite a number of cases were reported though many are still underreported due to
its protean manifestations. Table 2 gives a short review of different cases reported from
India. Most of these were reported from the southern part though Melioidosis may be more
widely prevalent. Two of the cases reported from Tamil Nadu actually originated from eastern
part of India.[4] DM has been found to be one of the most frequent predisposing factors.
Human infection occurs through inhalation or direct inoculation on damaged skin. Our patient
was exposed to recent floods, which could be the source of infection.

MALDI/TOF spectra are used for the identification of micro-organisms such as bacteria or
fungi. A portion of a colony of the microbe in question placed onto the sample target and
overlaid with matrix. The mass spectra generated are analyzed by dedicated software and
compared with stored profiles. Species diagnosis by this procedure is much faster, more
accurate and cheaper than other procedures based on immunological or biochemical tests.
MALDI/TOF may become the standard method for species identification in medical
microbiological laboratories over the next few years.[48]
Its main advantage over other microbiological identification methods is its ability to reliably
identify, at low cost and rapidly, a wide variety of micro-organisms directly from the selective
medium used to isolate/detect them. The absence of the need to purify the suspect (or
"presumptive") colony[49]allowing for much faster turn-around times.

Learning points

Acknowledgements
References
1.Chaowagul W, White NJ, Dance DA, et al. Melioidosis: a major
cause of community acquired septicemia in northeastern Thailand.
J Infect Dis 1989;159:890-9.
2. C heng AC, Jacups SP, Gal D, Mayo M, Currie BJ. Melioidosis
epidemiology and risk factors from a prospective whole population
study in northern Australia. Trop Med Inter Health 2004;9:1167-74.)
48. Seng, P.; Drancourt, M.; Gouriet, F.; La Scola, B.; Fournier, P. E.; Rolain, J. M.; Raoult,
D. (2009). "Ongoing revolution in bacteriology: routine identification of bacteria by matrixassisted laser desorption ionization time-of-flight mass spectrometry". Clinical Infectious
Diseases 49 (4): 5523. doi:10.1086/600885. PMID 19583519
49.Capocefalo M., Ridley E. V., Tranfield E. Y. & Thompson K. C. (2015). "Ch. 9 - MALDITOF: A rapid microbiological confirmation technique for food and water analysis". In Cook N.,
D'Agostino M. & Thompson K. C. Molecular Microbial Diagnostic Methods - Pathways to
Implementation for the Food and Water Industries. Elsevier. ISBN 978-0-12-416999-9.