BACKGROUND

Melioidosis is an infectious disease caused by Burkholderia pseudomallei. It is endemic in the Philippines and is underreported. Of the reported cases, the most common comorbidity is diabetes mellitus. The increasing cases of antibiotic resistance and the relatively high mortality rate highlights the need for increased awareness among clinicians regarding this disease. We aim to report a case of Burkholderia pseudomallei resistant to trimethoprim/sulfamethoxazole (TMP-SMX), used in its eradication following initial intravenous therapy.

A 51-year-old male Filipino with poor health-seeking behavior came with generalized body weakness, weight loss, dysarthria, fever, cough, difficulty breathing, bloatedness, dysuria, joint pains, and bilateral lower extremity hyperpigmented macules for four months. He has diabetes mellitus and hypertension and is a mechanic by trade. Initial workups revealed hemoglobin A1c (HbA1c) of 14.7%, and urinalysis with bacteriuria. Imaging revealed bilateral pneumonia on chest xray, hepatosplenomegaly on whole abdomen ultrasound, and old cerebral infarcts on cranial computed tomography scan (CT scan). Empiric antibiotics for the impression of sepsis from community-acquired pneumonia and urinary tract infection were ertapenem and azithromycin. Upon isolation of Burkholderia pseudomallei from blood cultures, the team shifted to TMP-SMX and ceftazidime for initial therapy of melioidosis. Sensitivity showed resistance to TMP-SMX; hence the team revised the antimicrobials to four weeks of levofloxacin and ceftazidime. After eleven hospital days, the team sent the patient home, clinically improved. The team continued levofloxacin for eradication therapy for three months and the patient responded well.

Fever with multi-system involvement in a Filipino patient with diabetes mellitus with significant environmental risk factors, poor glycemic control, splenomegaly, and treatment failure with appropriate empiric antibiotic therapy should raise suspicion for melioidosis. It is paramount that antimicrobial resistance be detected and documented upon isolation of Burkholderia pseudomallei, given the high relapse rates and the need for a prolonged duration of treatment.

Melioidosis is an infection caused by Burkholderia pseudomallei known to be endemic in large portions of Asia, Sub-Sahara, and North Australia. Despite its endemicity in Malaysia, prompt diagnosis and subsequent treatment remain elusive especially in the more peripheral medical centres. This coupled with increasing risk to the population because of worsening climate crises renders early recognition and treatment more justifiable than ever. Here we present a case of melioidosis septic arthritis with systemic dissemination and discuss the factors involved in disease contraction, worsening prevalence, and diagnostic methods.
Melioidosis ; Arthritis, Infectious ; mviN protein, Burkholderia pseudomallei [Supplementary Concept]

Background: Melioidosis is a potentially fatal disease caused by Burkholderia pseudomallei. Over a century after its discovery, there seems to be a paucity of reported cases in the Philippines relative to other countries where it is found to be endemic. This suggests that the true burden of melioidosis in the country is not well-defined. The rarity of the disease, its protean clinical manifestations, and the lack of pathognomonic features pose a great diagnostic challenge. Furthermore, the proper recognition of the organism is an extreme necessity as it is intrinsically resistant to numerous antibiotics and requires specific long-term treatment. Case: This is a case of a 49-year-old Filipino diagnosed with a metastatic spinal disease from a primary thyroid carcinoma and underwent posterior spinal decompression and stabilization. Revision of instrumentation was done following identification of an implant loosening. During the interim, wound dehiscence and infection developed. The patient was readmitted and underwent debridement of the lumbosacral spine. Wound cultures all yielded growth of Burkholderia pseudomallei. The patient received meropenem and then trimethoprim-sulfamethoxazole with ciprofloxacin during the intensive and eradication phase, respectively. Erythrocyte sedimentation rate and C-reactive protein were monitored and a significant reduction in both values reflected a good therapeutic response. Conclusion This is a rare case of a deep surgical site infection caused by Burkholderia pseudomallei. It is known that melioidosis is a potentially fatal infection but is under-reported in the Philippines. At present, further epidemiological studies along with an increased level of awareness of melioidosis are greatly needed to help define the true burden of illness and optimize patient management following prompt recognition.
Melioidosis ; Philippines ; Burkholderia pseudomallei

BACKGROUND: Musculoskeletal involvement in melioidosis is often seen in conjunction with a disseminated illness. Recent reports suggest that operative management of musculoskeletal melioidosis has favourable results. The purpose of this study was to review the patient profile and clinical outcomes of Burkholderia pseudomallei infection in the musculoskeletal system. METHODS: Hospital records of 163 patients who were diagnosed to have B. pseudomallei infection between January 2009 and December 2014 were reviewed. Patients underwent surgical and nonsurgical management depending upon the tissue of involvement. Epidata software was used to record the data. The SPSS ver. 17.0 was used for analysis. RESULTS: Eighteen out of 24 patients who had musculoskeletal melioidosis were available for follow-up. Septic arthritis, osteomyelitis, and intramuscular abscess were the common diagnosis, with 6 patients in each group. Twelve patients required surgical intervention. All patients received a full course of parenteral ceftazidime followed by oral doxycycline and co-trimoxazole. Two out of 6 patients (33.3%) died among those who had nonsurgical management as compared to none in the group who had surgical management. This was significant at 10% level of significance (p = 0.098). The rest were followed up for a minimum of 1 year with no evidence of disease recurrence. CONCLUSIONS: This series describing musculoskeletal involvement in melioidosis is the largest such study from a recently recognized ‘endemic’ region. Of importance are the patterns of musculoskeletal involvement, pitfalls in diagnosis and adequate clinical response with timely diagnosis and appropriate surgical management.
Abscess ; Arthritis, Infectious ; Burkholderia pseudomallei* ; Burkholderia* ; Ceftazidime ; Debridement ; Diagnosis ; Doxycycline ; Follow-Up Studies ; Hospital Records ; Humans ; Melioidosis ; Musculoskeletal System ; Osteomyelitis ; Recurrence ; Synovitis ; Trimethoprim, Sulfamethoxazole Drug Combination

Melioidosis is an infectious disease caused by an aerobic, non-spore forming gram negative bacillus, Burkholderia pseudomallei. It is known to be of high incidence in parts of rural South East Asia, and in Northern Australia. Pneumonia is the commonest manifestation. We report here three cases of neurological melioidosis from the registry of 169 cases of melioidosis in Bintulu Hospital, Sarawak, East Malaysia, with a review of neurological melioidosis in the literature. The annual incidence of melioidosis is estimated to be 8 per 100,000 populations in the Bintulu district. Neurological melioidosis accounts for 1.8% of our melioidosis cases. A review of 76 cases of neurological melioidosis reported in the literature inclusive of our 3 cases shows that localized brain or spinal inflammation or abscess is the most common manifestation occurring in 80% of patients. Close to half (53%) have intra axial abscess (brain or spinal cord), a quarter (27%) have extra axial lesions only (epidural or subdural collection, osteomyelitis or scalp abscess), and another quarter (27%) have both intra and extra axial lesions. Thus, B. pseudomallei appears to be unique among the bacterial central nervous system infection to be able to affect the brain and its contiguous tissues, crossing the tissue plane particularly resulting in osteomyelitis, scalp abscess and vice versa. Two thirds of the neurologicalmelioidosis patients have only neurological disease with no evidence of disease elsewhere. Key words: Burkholderia pseudomallei; neurological melioidosis; Bintulu; Sarawak; Malaysia
Melioidosis

PURPOSE: Hospital-acquired Burkholderia cepacia (B. cepacia) infection are not commonly recorded in patients without underlying lung disease, such as cystic fibrosis and chronic granulomatous disease. However, in 2014, B. cepacia appeared more frequently in pediatric blood samples than in any other year. In order to access this situation, we analyzed the clinical characteristics of B. cepacia infections in pediatric patients at our hospital. MATERIALS AND METHODS: We conducted a retrospective study of blood isolates of B. cepacia taken at our hospital between January 2004 and December 2014. Patient clinical data were obtained by retrospective review of electronic medical records. We constructed a dendrogram for B. cepacia isolates from two children and five adult patients. RESULTS: A total of 14 pediatric patients and 69 adult patients were identified as having B. cepacia bacteremia. In 2014, higher rates of B. cepacia bacteremia were observed in children. Most of them required Intensive Care Unit (ICU) care (12/14). In eleven children, sputum cultures were examined, and five of these children had the same strain of B. cepacia that grew out from their blood samples. Antibiotics were administered based on antibiotic sensitivity results. Four children expired despite treatment. Compared to children, there were no demonstrative differences in adults, except for history of ICU care. CONCLUSION: Although there were not many pediatric cases at our hospital, awareness of colonization through hospital-acquired infection and effective therapy for infection of B. cepacia is needed, as it can cause mortality and morbidity.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents/therapeutic use ; Bacteremia/drug therapy/*epidemiology ; Burkholderia Infections/blood/drug therapy/*epidemiology ; Burkholderia cepacia/drug effects/*isolation & purification ; Child ; Child, Preschool ; Cross Infection/blood/*diagnosis/drug therapy/mortality ; Disease Outbreaks ; Female ; Humans ; Incidence ; Infant ; *Intensive Care Units ; Male ; Microbial Sensitivity Tests ; Middle Aged ; Republic of Korea/epidemiology ; Retrospective Studies ; Treatment Outcome ; Young Adult

STUDY DESIGN: Retrospective clinical analysis. PURPOSE: To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. OVERVIEW OF LITERATURE: Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei, has been labeled as a bio-terrorism agent. METHODS: We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels. RESULTS: Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up. CONCLUSIONS: Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.
Abscess ; Anti-Bacterial Agents ; Back Pain ; Blood Sedimentation ; Burkholderia pseudomallei ; C-Reactive Protein ; Ceftazidime ; Delivery of Health Care ; Developing Countries ; Diabetes Mellitus ; Diagnosis ; Discitis ; Doxycycline ; Drainage ; Follow-Up Studies ; Health Education ; Hematologic Tests ; Humans ; Inflammation ; Leukocytosis ; Magnetic Resonance Imaging ; Melioidosis ; Mortality ; Neutrophils ; Psoas Abscess ; Radiography ; Retrospective Studies ; Return to Work ; Spine ; Spondylitis* ; Surgeons ; Trimethoprim, Sulfamethoxazole Drug Combination ; Tuberculosis

Melioidosis, which is an infectious disease caused by Burkholderia pseudomallei, is prevalent mostly in Southeast Asia and northern Australia; it can progress to abscess formation, pneumonia and sepsis, and ultimately cause death. A 66-yr-old male patient with diabetes mellitus was hospitalized for sepsis 3 months after coming back from Cambodia, and B. pseudomallei was identified from the blood culture. The B. pseudomallei strain was found to be susceptible to carbapenem, and non-susceptible to trimethoprim/sulfamethoxazole and ceftazidime. Although the patient was treated with carbapenem, to which the strain was susceptible, the bacteremia persisted, and progressed to septic shock and pneumonia, and eventually to acute respiratory distress syndrome (ARDS). The patient died on the 12th day of hospitalization. This study, which reports the first case of ceftazidime-nonsusceptible B. pseudomallei in Korea, indicates the importance of B. pseudomallei infection, which is highly likely to be imported to Korea, and discuss its clinical progress, which can lead to fatality.
Abscess ; Asia, Southeastern ; Australia ; Bacteremia ; Burkholderia pseudomallei* ; Burkholderia* ; Cambodia ; Ceftazidime ; Communicable Diseases ; Diabetes Mellitus ; Hospitalization ; Humans ; Korea ; Male ; Melioidosis ; Pneumonia ; Respiratory Distress Syndrome, Adult ; Sepsis ; Shock, Septic

PURPOSE: Burkholderia cepacia is an aerobic, glucose-non-fermenting, gramnegative bacillus that mainly affects immunocompromised and hospitalized patients. Burkholderia cepacia has high levels of resistance to many antimicrobial agents, and therapeutic options are limited. The authors sought to analyze the incidence, clinical manifestation, risk factors, antimicrobial sensitivity and outcomes of B. cepacia urinary tract infection (UTI) in pediatric patients. METHODS: Pediatric patients with urine culture-proven B. cepacia UTI between January 2000 and December 2014 at Samsung Medical Center, a tertiary referral hospital in Seoul, Republic of Korea, were included in a retrospective analysis of medical records. RESULTS: Over 14 years, 14 patients (male-to-female ratio of 1:1) were diagnosed with B. cepacia UTI. Of 14 patients with UTI, 11 patients were admitted to the intensive care unit, and a bladder catheter was present in 9 patients when urine culture was positive for B. cepacia. Patients had multiple predisposing factors for UTI, including double-J catheter insertion (14.2%), vesico-ureteral reflux (28. 6%), congenital heart disease (28.6%), or malignancy (21.4%). Burkholderia cepacia isolates were sensitive to piperacillin-tazobactam and sulfamethoxazole-trimethoprim, and resistant to amikacin and colistin. Treatment with parenteral or oral antimicrobial agents including piperacillin-tazobactam, ceftazidime, meropenem, and sulfamethoxazole-trimethoprim resulted in complete recovery from UTI. CONCLUSION: Burkholderia cepacia may be a causative pathogen for nosocomial UTI in pediatric patients with predisposing factors, and appropriate selection of antimicrobial therapy is necessary because of high levels of resistance to empirical therapy, including aminoglycosides.
Amikacin ; Aminoglycosides ; Anti-Infective Agents ; Bacillus ; Burkholderia cepacia* ; Burkholderia* ; Catheters ; Causality ; Ceftazidime ; Child* ; Colistin ; Heart Defects, Congenital ; Humans ; Incidence ; Intensive Care Units ; Medical Records ; Republic of Korea ; Retrospective Studies ; Risk Factors ; Seoul ; Tertiary Care Centers ; Urinary Bladder ; Urinary Tract Infections* ; Urinary Tract* ; Vesico-Ureteral Reflux

Burkholderia cepacia is a highly virulent pathogen known to cause opportunistic infections in immunocompromised patients. It accelerates lung disease and causes necrotizing pneumonia with associated severe sepsis, known as cepacia syndrome. In particular, lung transplant recipients infected with Burkholderia cepacia show higher mortality after lung transplantation than those who are not infected with this organism. Due to broad-spectrum antibiotic resistance, a combination therapy should be used according to the results of the susceptibility test. This bacterial infection is rare in Korea, and no case was reported in lung transplant recipients. However, we report a case of pneumonia caused by Burkholderia cepacia after lung transplantation. As Burkholderia cepacia was grown from a sputum culture, the patient was treated initially with a combination of meropenem and trimethoprim/sulfamethoxazole and then ceftazidime and trimethoprim/sulfamethoxazole as a result of leukopenia. After antibiotics treatment for 20 days, sputum cultures became negative for Burkholderia cepacia and the patient successfully recovered.
Anti-Bacterial Agents ; Bacterial Infections ; Burkholderia ; Burkholderia cepacia ; Ceftazidime ; Cystic Fibrosis ; Drug Resistance, Microbial ; Humans ; Immunocompromised Host ; Korea ; Leukopenia ; Lung ; Lung Diseases ; Lung Transplantation ; Opportunistic Infections ; Pneumonia ; Sepsis ; Sputum ; Thienamycins