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| CASE REPORT |
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| Year : 2023 | Volume
: 6
| Issue : 2 | Page : 81-83 |
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Melioidosis: Spectrum of presentation
H Ria Lawrence, Gayathri Anur Ramakrishnan
Department of Respiratory Medicine, Apollo Hospital, Chennai, Tamil Nadu, India
| Date of Submission | 03-May-2023 |
| Date of Decision | 01-Jun-2023 |
| Date of Acceptance | 05-Jun-2023 |
| Date of Web Publication | 13-Jul-2023 |
Correspondence Address:
Dr H Ria Lawrence
Department of Respiratory Medicine, Apollo Hospital, Greams Road, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/japt.japt_17_23
Melioidosis is caused by Burkholderia pseudomallei, which is normally present in soil, endemic in the tropical and subtropical regions. It has a varied clinical presentation from presenting with acute symptoms and sepsis and rarely presenting as subacute to chronic disease. In this article, we have discussed the spectrum of presentation of melioidosis such as mediastinal lymphadenopathy, cavitating pneumonia, and pleural effusion.
Keywords: Burkholderia in India, melioidosis, melioidosis in India, melioidosis lymphadenopathy, melioidosis pleural effusion
How to cite this article:
Lawrence H R, Ramakrishnan GA. Melioidosis: Spectrum of presentation. J Assoc Pulmonologist Tamilnadu 2023;6:81-3 |
| Introduction | |  |
Melioidosis is an infection caused by Gram-negative bacteria, Burkholderia pseudomallei. South Asia is estimated to have 44% of the global burden of melioidosis.[1] Incidence of melioidosis in India remains underdiagnosed and underreported because of similar common characteristics of this disease with other infections. Here, we report a case series of three patients with culture-proven melioidosis with varied clinical presentation.
| Case Reports | | |
Case 1 – Mediastinal lymphadenopathy
A 52-year-old female from Assam, known diabetic, came with complaints of fever for 1 week and cough with expectoration for 2 weeks. There was no hemoptysis, chest pain, wheeze or loss of weight, or appetite. On examination, she was afebrile and saturating well on room air, and on auscultation, the chest was clear. Computed tomography (CT) chest [Figure 1] showed patchy ground-glass opacities in the right upper lobe and solid nodule in the right lower lobe. Multiple enlarged, conglomerate lymph nodes were seen in prevascular, pretracheal, subcarinal, and right hilar nodes with areas of necrosis. CT-guided biopsy of the lesion was done which was negative for acid-fast bacilli (AFB) stain and GeneXpert Mycobacterium tuberculosis (MTB). Bacterial culture showed B. pseudomallei. Cytology showed subacute inflammation. She was started on tablet doxycycline and showed improvement after 2 weeks. | Figure 1: CT CHEST showing patchy ground-glass opacities in the right upper lobe and solid nodule in the right lower lobe. Multiple enlarged, conglomerate lymph nodes were seen in prevascular, pretracheal, subcarinal, and right hilar nodes with areas of necrosis
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Case 2 – Parapneumonic effusion
A 44-year-old female, known diabetic, came with complaints of intermittent fever and right-sided chest pain for 2 months. There was a history of loss of weight and appetite for 4 weeks. On examination, she was afebrile and saturating well on room air, and on auscultation, right basal reduced air entry was seen. Chest X-ray showed right lower zone opacities. CT chest [Figure 2] showed right lower lobe consolidation and right-sided pleural effusion. Pleural fluid tapping was done which showed exudative neutrophilic inflammation. Pleural fluid culture grew B. pseudomallei. She was started on intravenous (IV) ceftazidime. She improved clinically, and chest X-ray [Figure 3] done during follow-up revealed clearing of right lower zone opacities. | Figure 2: CT CHEST showing right lower lobe consolidation and right-sided pleural effusion
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Case 3 – Lung cavity
A 55-year-old male, from Tripura, known diabetic, smoker came with complaints of fever for 2 months, dry cough for 2 weeks, and right-sided chest pain for 1 week. On examination, he was afebrile and saturating well on room air, and on auscultation, the chest was clear. CT chest [Figure 4] revealed multiple discrete centrilobular nodules (6–7 mm) and tree-in-bud opacities in all lobes. Few larger nodules showed central cavitation. Bronchoscopy was done which revealed bilateral inflamed mucosa with thin secretions. Bronchoalveolar lavage was done which was negative for AFB stain and GeneXpert MTB. Bacterial culture grew B. pseudomallei. He was started on IV meropenem, and he gradually improved. | Figure 4: CT CHEST showing multiple discrete centrilobular nodules (6–7 mm) and tree-in-bud opacities in all lobes
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| Discussion | | |
Melioidosis is caused by B. pseudomallei, which is normally present in soil, endemic in the tropical and subtropical regions. It is common in males, and diabetes is an important risk factor. Melioidosis often presents as an acute-onset severe disease with a case fatality rate of about 10%–50%.[2] The mortality rate among treated patients is about 14%–40% and >80% in untreated patients.[3] In patients with disseminated melioidosis with septicemia, the mortality is as high as 82%–87% of the patients.[4] It is, therefore, most crucial to diagnose the disease promptly with appropriate and adequate samples for culture of organisms. B. pseudomallei is a Gram-negative, bipolar, aerobic, motile rod-shaped bacterium in the culture.
| Conclusion | | |
In our study, we have seen a varied presentation of melioidosis with mediastinal lymphadenopathy, pleural effusion, and pulmonary cavity. The diagnosis of melioidosis is often missed or underreported due to many reasons. One such important reason being, the presentation of melioidosis masquerades as a tuberculous infection which is much more common in India. In laboratory diagnosis, the culture growth of Gram-negative bacteria can be misinterpreted as other bacteria such as Pseudomonas, which shows the importance of following the culture growth up to the species level. Treatment consists of two phases: acute phase and eradication phase. In the acute phase, IV ceftazidime every 6–8 h or IV meropenem every 8 h can be given and for severe patients for 2–3 weeks course depending on the clinical progression. In the eradication phase, the main purpose is to get rid of any residual bacteria that might cause relapse at a later stage. Co-trimoxazole and doxycycline can be given in this phase for 4–6 weeks.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgments
We would like to thank the Department of Respiratory Medicine, Department of Infectious Disease, and Department of Microbiology.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Mohapatra PR, Mishra B. Burden of melioidosis in India and South Asia: challenges and ways forward. The Lancet Regional Health-Southeast Asia 2022.  |
| 2. | Wiersinga WJ, Virk HS, Torres AG, Currie BJ, Peacock SJ, Dance DA, et al. Melioidosis. Nat Rev Dis Primers 2018;4:17107. |
| 3. | Cabibbo G, Enea M, Attanasio M, Bruix J, Craxì A, Cammà C. A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma. Hepatology 2010;51:1274-83. |
| 4. | Leelarasamee A. Burkholderia pseudomallei: The unbeatable foe? Southeast Asian J Trop Med Public Health 1998;29:410-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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