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Acute Disseminated Melioidosis Presenting with Septic
Arthritis and Diffuse Pulmonary Consolidation in an
Otherwise Healthy Adult: A Case Report
Hai Sherng Lee,1 Abdul Azeez Ahamed Riyaaz,1 Seng Hong Yeoh.1
Background: Melioidosis is an infectious disease caused by Burkholderia pseudomallei. It is most prevalent in South-East Asia, northern Aus-
tralia, and the Indian subcontinent. Septic arthritis is a rare manifestation of melioidosis. Melioidosis is usually found in patients with diabe-
tes, heavy alcohol use, or chronic lung disease. Case: We report a case of melioidosis in an otherwise healthy 44-year-old male, who presented
with acute painful left knee swelling, high-grade fever associated with chills, rigors and night sweats, and a productive cough. Examination
revealed active synovitis with effusion involving his left knee, ankle and elbow joints and scattered crackles over both lung fields. Chest X-ray
showed diffuse pulmonary consolidation. Abdominal ultrasound showed splenic micro-abscesses. The diagnosis was made based on a positive
blood culture for Burkholderia pseudomallei. He was started on appropriate antibiotics and responded well, becoming afebrile after 48 hours,
while his joint effusions disappeared after one week. Conclusion: Septic arthritis only occurs in 4% of patients with melioidosis. When there
is diffuse pulmonary involvement, melioidosis may mimic disseminated tuberculosis, sepsis syndromes, and systemic vasculitis syndromes.
This case is relevant for medical literature as melioidosis is emerging and is expanding its territories worldwide. It should be considered early
in the differential diagnoses in endemic areas so that treatment can be started early to reduce its high mortality and morbidity.
Keywords: Abscess; Adult; Arthritis, Infectious; Burkholderia pseudomallei; Melioidosis (Source: MeSH, NLM).
About the Author: Dr Hai Melioidosis is an infectious disease caused by the gram-negati-
• Melioidosis is endemic in tropical regions like South-East Asia and Sherng Lee is currently ve saprophyte Burkholderia pseudomallei. It is most prevalent northern Australia and is usually found in patients with diabetes, heavy working at the Wollongong alcohol use, or chronic lung disease.
in South-East Asia, northern Australia, and the Indian subconti- Hospital in New South Wa- • Septic arthritis is a rare manifestation of melioidosis, found in only 4% les, Australia. He graduated nent.1 It is usually found in patients with diabetes, heavy alco- of the cases at presentation.
from Monash University hol use, or chronic lung disease.1 The common manifestations • Mortality rates for melioidosis vary from 14% in Australia to 40% in and was awarded, in his are pneumonia (in half of all cases), genitourinary infection, northeast Thailand.
final year, "Excellence in skin infection, and bacteraemia without evident focus.2 Compli- • The standard treatment for melioidosis comprises 10-14 days of intra- Pre-Intern Assessment" un- venous ceftazidime or meropenem, followed by oral trimethoprim-sul- der the Acute General Sur- cations include septic shock. Recurrent melioidosis is common famethoxazole (TMP-SMX) plus doxycycline taken every 12 hours for 3 gery Unit at the School of unless long courses of treatment are given, and high mortality to 6 months.
Clinical Sciences, Monash rates ranging from 14% to 40% have been reported despite • Melioidosis is becoming an emerging infection and expanding its te- Health, Victoria, Australia. optimal therapy.1,2 rritories worldwide. Due to its high mortality and morbidity, it shouldbe considered early in the differential diagnoses of patients presentingwith constitutional symptoms in endemic areas.
This case is unusual as the patient had none of the risk factors known to be associated with this infection and pre- sented with septic arthritis, which is a rare presenting fea- A 44-year-old male of Chinese ethnicity, who was previously ture. It is an uncommon but important disease for clinicians healthy, presented to a district hospital in the state of Johor, to consider as its manifestations are protean, and it can Malaysia on July 28, 2014, complaining of a one-week his- mimic many diseases, including pulmonary tuberculosis.1,2 tory of acute onset painful swelling of his left knee. He had Melioidosis should be considered as part of the differential also developed a productive cough with scanty yellowish diagnosis of patients with sepsis or abscesses in endemic sputum, as well as high-grade fever associated with chills, regions. It is being recognized more frequently in these re- rigors, and night sweats of similar duration. Three days be- gions and is one of the important emerging infections that fore hospital admission, his left ankle and elbow joints were clinicians will encounter more in the future.2,3 Informed wri- noted to be swollen and painful. He denied any recent trau- tten consent was obtained from the patient for writing and ma. Findings from a review of his cardiovascular, gastroin- publishing this case report.
testinal, and genitourinary systems were normal. His past Submission: Sep 30, 2014Acceptance: Feb 23, 2015Publication: Mar 30, 2015Process: Peer-reviewed1 Monash University, Malaysia.
Address: Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor, Malaysia.
Int J Med Students • 2015 2014 Nov-2015 Mar Vol 3 Issue 1 The International Journal of Medical Students
Lee HS, et al.
Acute Disseminated Melioidosis Presenting with Septic Arthritis and Diffuse Pulmonary Consolidation in an Otherwise Healthy Adult: A Case Report medical history was unremarkable, and there was no family Figure 1. Patient's Chest X-ray, Showing Bilateral Diffuse Patchy
history of autoimmune diseases. He denied any recent tra- Opacities Suggestive of Consolidation.
vel outside his state and contact with people with active pulmonary tuberculosis. He was a current smoker and had smoked around 16 cigarette pack-years since the age of 18. He drank alcohol only during social events and denied illicit drug use and high-risk sexual behaviours. He has worked as a tile layer for many years, during which he had occasional contact with the soil.
Examination revealed a man of average build, who appea-red ill and mildly dyspnoeic. Upon admission, his vital signs included a pulse rate of 110 beats/min, a blood pressure of 110/61 mmHg, and a respiratory rate of 24 breaths/min. His temperature was 38.5 oC, and there were no pallor, icterus, lymphadenopathy, or skin rash noted. Respiratory examination revealed only scattered bilateral crackles while a mild hepa-tosplenomegaly was felt upon abdominal examination. His left knee, ankle, and elbow joints showed signs of active synovitis with effusion.
Investigations showed a white cell leukocytosis (22.2 x 109/L) Figure 2. Patient's Left Knee with Effusion that had been Ban-
with neutrophilia (86.4%) and deranged liver function tests daged and Drained.
[alanine transaminase (ALT): 56.2 U/L, aspartate aminotrans-
ferase (AST): 54.7 U/L, and alkaline phosphatase (ALP): 447.2
U/L]. Other investigations, including urine dipstick and re-
nal profile, were normal. Chest X-ray showed bilateral diffu-
se patchy opacities suggestive of consolidation (Figure 1).
An ultrasound of his abdomen confirmed mild hepatosple-
nomegaly and multiple irregular small hypo-dense lesions
scattered in the spleen parenchyma, likely to represent mi-
cro-abscesses. At this point, a working diagnosis of septi-
caemia of unknown focus was made, and he was started on
intravenous co-amoxiclav to cover the broad spectrum. Spu-
tum samples were sent for acid-fast bacilli to rule out active
pulmonary tuberculosis and came back negative. A human
immunodeficiency virus (HIV) screening test was negative.
He underwent aspiration of his left knee joint effusion, and a
drainage catheter was inserted (Figure 2). The joint fluid was
yellowish and clear, with no organisms detected on Gram's Figure 3. Patient's Repeat Chest X-ray After Two Weeks of Anti-
stain and culture.
biotics, Showing Marked Radiological Improvement.
On day two of hospital admission, his blood culture grew Bur-
kholderia pseudomallei, leading to the diagnosis of dissemi-
nated melioidosis. He was started on intravenous ceftazidime
2 g three times daily and two tablets of oral co-trimaxazole
960 mg twice daily based on sensitivity results. He became
afebrile after 48 hours, while his joint effusions disappeared
over the first week of antibiotic treatment. The patient had
to stay as an inpatient for two weeks for the intensive phase
of intravenous antibiotic therapy, during which he did not
develop any complications. A repeat chest X-ray done after
two weeks of intensive antibiotic therapy showed marked
radiological improvement (Figure 3). He was discharged home
after two weeks, with a plan of continuation of oral co-tri-
maxazole for another 20 weeks and outpatient follow-up at
4-6 weeks intervals. Our patient believed that he acquired
the infection at his workplace and was satisfied with the
treatment he received. He understood the protracted nature
of his illness and was committed to completing his prolonged
The International Journal of Medical Students Int J Med Students • 2015 2014 Nov-2015 Mar Vol 3 Issue 1 Case Report
Lee HS, et al.
Acute Disseminated Melioidosis Presenting with Septic Arthritis and Diffuse Pulmonary Consolidation in an Otherwise Healthy Adult: A Case Report patients with melioidosis have one or more risk factors for the Melioidosis is caused by the environmental Gram-negative soil disease, which include diabetes, heavy alcohol use, chronic saprophyte B. pseudomallei. Melioidosis is endemic in Sou- pulmonary disease, chronic kidney disease, and thalassaemia. th-East Asia and northern Australia, with increasing recogni- Glucocorticoid therapy and cancer were only associated in less tion in the Indian subcontinent and elsewhere in the tropics. than 5% of cases.1-3 Our patient, however, had no such known Northeast Thailand reports the highest number of cases, with risk factors.
an annual incidence of 50 cases per 100,000 people, making melioidosis the third most common cause of death due to The diagnosis of melioidosis is made from a positive culture infectious diseases in northeast Thailand.1 In Darwin, tropical for B. pseudomallei from any clinical sample, which in our Australia, a 20-year prospective study from October 1989 yiel- patient's case was a positive blood culture. We would have ded 540 cases of melioidosis.2 Melioidosis has been studied faced diagnostic difficulties if the culture had been negati-extensively only in certain regions of Malaysia where there is ve due to the non-availability of serological or genetic-based known to be a higher incidence of disease. For instance, there testing at the hospital where the patient was treated. But the were 44 new cases of melioidosis in the Malaysian state of delay in the identification of B. pseudomallei or misidentifi-Johor between January 1999 and December 2003.4 Melioidosis cation as another species is not uncommon in laboratories is an emerging disease, as evidenced by increased reported that are unfamiliar with this organism.5 A direct polymera-incidence in endemic regions. For example, in Darwin, the se-chain-reaction assay of a clinical sample may be useful prospective study identified 88 cases in the first five years, to provide a more rapid result than culture, but the assay which increased steadily to 149 cases in the final five years.2 is less sensitive, especially when performed on blood sam- In Northeast Thailand, there were 198 cases in 1997, which ples.6 Serologic testing alone is not adequate to confirm the increased to 380 cases in 2006.3 In addition, cases are being diagnosis, especially in endemic regions where background identified in new areas where melioidosis has not previously seropositivity is common.7 The treatment of melioidosis inclu-been reported.1 des prolonged courses of appropriate antibiotics due to the recalcitrant nature of the infection. An initial intensive phase The primary modes of transmission of melioidosis are thought should include at least 10 to 14 days of intravenous cefta- to be percutaneous inoculation in persons who are in regular zidime or meropenem followed by oral eradication therapy, contact with soil and water and, less commonly, via inhala- which comprises trimethoprim-sulfamethoxazole (TMP-SMX) tion during severe stormy weather or by ingestion of contami- taken every 12 hours for 3 to 6 months, with or without doxy- nated food or water.1 Melioidosis is predominantly seasonal, cyline.5 TMP-SMX plus doxycycline is considered the standard and more than 75% of cases occur during the rainy season. B. oral eradication regimen, although one recent study showed pseudomallei can invade macrophages and survive and repli- that TMP-SMX alone is not inferior to TMP-SMX with doxycy- cate for extended periods of time. Phagocytes may be able to cline.8 Amoxicillin–clavulanate can be used as an alternative destroy the bacteria, but some bacteria can escape endocytic agent for eradication therapy when there are contraindica-vacuoles and enter into the cytoplasmic space. They are also tions for the use of TMP-SMX.9capable of infecting other cells through actin-based membrane protrusions.1 Mortality rates in melioidosis vary from region to region. For instance, it is approximately 40% in northeast Thailand,5 but Melioidosis has a wide array of clinical signs and symptoms. It 14% in Australia.2 Recurrent melioidosis occurs in approxima- has an incubation period of 1-21 days, with a mean of 9 days, tely 1 in 16 patients, often in the first year after the initial although prolonged periods of latency (up to 62 years) have presentation. Nearly 25% of recurrences are due to reinfection, been reported.1 Its severity varies from an acute fulminant sep- with the remainder due to relapses from a persistent focus of tic illness to a chronic infection, in which symptoms last for infection.10more than two months and may mimic malignancy or tubercu-losis. In a descriptive study done over 20 years in tropical Aus- In conclusion, septic arthritis only occurs in 4% of patients tralia, the most common presenting feature was pneumonia, presenting with melioidosis.2 When there is diffuse pulmonary which was present in 50% of cases, followed by genitourinary involvement, it may mimic disseminated tuberculosis, other infection, skin infection, and bacteraemia without evident fo- acute disseminated or focal sepsis syndromes, and systemic cus.2 Septic arthritis, which was the principal presentation of vasculitis syndromes.1,2 This case is relevant to the medical our patient, and septic osteomyelitis are rare presenting fea- literature as melioidosis is becoming an emerging infection and tures, with only 4% of cases having such manifestations. Over expanding its territories worldwide. It should be considered half of patients have bacteraemia on presentation, and septic early in the differential diagnoses of patients presenting with shock develops in approximately one fifth. Internal-organ abs- constitutional symptoms in areas where it is known to be en- cesses and secondary foci in the lungs, skin and soft tissues, demic so that treatment can be started early to reduce its high bones and joints, or any other organ may occur. Up to 80% of mortality and morbidity.2,3 Int J Med Students • 2015 2014 Nov-2015 Mar Vol 3 Issue 1 The International Journal of Medical Students
Lee HS, et al.
Acute Disseminated Melioidosis Presenting with Septic Arthritis and Diffuse Pulmonary Consolidation in an Otherwise Healthy Adult: A Case Report 7. Wuthiekanun V, Chierakul W, Langa S, Chaowagul W, Panpitpat C, Saipan 1. Wiersinga WJ, Currie BJ, Peacock SJ. Melioidosis. N Engl J Med. 2012 Sep P, et al. Development of antibodies to Burkholderia pseudomallei during childhood in melioidosis-endemic northeast Thailand. Am J Trop Med Hyg.
2. Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl 8. Chetchotisakd P, Chierakul W, Chaowagul W, Anunnatsiri S, Phimda K, Moot- Trop Dis. 2010 Nov 30;4(11):e900.
sikapun P, et al. Trimethoprim-sulfamethoxazole versus trimethoprim-sulfa- 3. Limmathurotsakul D, Wongratanacheewin S, Teerawattanasook N, Wongsu- methoxazole plus doxycycline as oral eradicative treatment for melioidosis van G, Chaisuksant S, Chetchotisakd P, et al. Increasing incidence of human (MERTH): a multicentre, double-blind, non-inferiority, randomised controlled melioidosis in Northeast Thailand. Am J Trop Med Hyg. 2010 Jun;82(6):1113-7.
trial. Lancet. 2014 Mar 1;383(9919);807-14.
4. Pagalavan L. Melioidosis: the Johor Bahru Experience. Med J Malaysia. 2005 9. Cheng AC, Chierakul W, Chaowagul W, Chetchotisakd P, Limmathurotsakul D, Dance DA, et al. Consensus guidelines for dosing of amoxicillin-clavulana- 5. Peacock SJ, Schweizer HP, Dance DA, Smith TL, Gee JE, Wuthiekanun V, et al. te in melioidosis. Am J Trop Med Hyg. 2008 Feb;78(2):208-9.
Management of accidental laboratory exposure to Burkholderia pseudomallei 10. Limmathurotsakul D, Chaowagul W, Chierakul W, Stepniewska K, Mahar- and B. mallei. Emerg Infect Dis. 2008 Jul;14(7):e2.
jan B, Wuthiekanun V, et al. Risk factors for recurrent melioidosis in nor- 6. Richardson LJ, Kaestli M, Mayo M, Bowers JR, Tuanyok A, Schupp J, et al.
theast Thailand. Clin Infect Dis. 2006 Oct 15;43(8):979-86.
Towards a rapid molecular diagnostic for melioidosis: comparison of DNA extrac-tion methods from clinical specimens. J Microbiol Methods. 2012 Jan;88(1):179-81.
We would like to thank the Department of Microbiology and Department of Radiology of Segamat Hospital for their assistance.
Conflict of Interest Statement & Funding
The authors has no funding, financial relationships or conflicts of interest to disclose.
Conception and design the work/idea: HSL, AZAR. Collect data/obtaining results, Analysis and interpretation of data: HSL, SHY. Write the
manuscript: HSL. Critical revision of the manuscript, Approval of the final version: AZAR.
Lee HS, Ahamed-Riyaaz AA, Yeoh SH. Acute Disseminated Melioidosis Presenting with Septic Arthritis and Diffuse Pulmonary Consolidation
in an Otherwise Healthy Adult: A Case Report. Int J Med Students. 2014 Nov-2015 Mar;3(1):59-62.
The International Journal of Medical Students Int J Med Students • 2015 2014 Nov-2015 Mar Vol 3 Issue 1
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