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40sh male, diabetic, non-complaint with medication brought to the ED with two weeks H/O
fever + cough and shoulder pain. N&V +
Exam: Icteric +
VS: 120/min BP: 100/70 RR: 38/min SpO2: 88% RA
RS: Creps B/L, bronchial breath sounds + Other systems: NAD

What is Melioidosis?

Melioidosis is a life threatening disease caused by a gram-negative bacterium known as

Burkholderia pseudomallei.
This disease has enormous clinical diversity, from asymptomatic infection to localized
skin ulcers or abscesses, chronic pneumonia mimicking tuberculosis to fulminant septic
shock with abscesses in multiple internal organs.
It is mostly found in tropical areas throughout the world, particularly in South East Asia
and northern Australia.


Gram-negative, oxidase-positive, motile, aerobic bacillus

Potential bio warfare agent
Recovered on standard culture medium
May be misidentified as other Pseudomonas species.
These bugs live below the soils surface during the dry season but after heavy
rainfall are found in surface water and mud and may become airborne.


Percutaneous inoculation

Incubation period: 1 to 21 days (variable), Latent infections

Facultative Intracellular organism, evades the host immune system
Wide range of virulence factors

What are the signs and symptoms?

Varied clinical spectrum ranging from acute or chronic, local or systemic, sub-clinical
or clinical disease (the remarkable imitator)

LOCALISED DISEASE: Muscle Aches, Ulcers, Boils, Skin abscess

PULMONARY: Commonest presentation (>50%), Cough, Expectoration
BLOOD STREAM INFECTION: Internal Abscess, DM, Renal Failure, Shock
DISSEMINATED INFECTION: Internal Abscesses, joint pain, headache, seizures

Genitourinary (Pyelonephritis), Joints (Septic Arthritis), Bones (Osteomyelitis), Skin

Ulcers/Abscesses, Multiple internal organ abscesses (Liver, Spleen, Prostate, psoas
major, pancreas, parotid), CNS (abscess, meningoencephalitis)
Infection can remain latent for decades and get reactivated (like tuberculosis). Disease may
occur years after the initial infection.

HIGH-RISK POPULATION FOR MELIOIDOSIS: Diabetics, heavy alcohol consumers,

kidney disease, lung disease, and cancer and those on immunosuppressive therapy
including steroids.


May be misidentified
Isolation from blood, sputum, urine or a swab from an abscess or non-healing ulcer
Peculiar Antibiotic Resistance Pattern (Resistant to Gentamycin/Colistin but
sensitive to Amoxicillin-Clavulanic acid)

How do we treat Melioidosis?
Two staged treatmentan intravenous high intensity stage and an oral maintenance stage
to prevent recurrence.
Initiation Phase (2 weeks): Ceftazidime/ Carbepenems with or without Cotrimoxazole
Eradication Phase (3-5 Months): Cotrimoxazole/ Doxycycline
Supportive Care
Surgical Drainage of large abscesses

Key Points:

In endemic regions, acute RS symptoms think Melioidosis!

Big risk factors: Diabetes, Renal Failure
Liaise with Microbiologist, tell them what you want them to look for
Complete both the treatment phases to prevent disease recurrence

1. Wiersinga, W. Joost, et al. "Melioidosis: insights into the pathogenicity of
Burkholderia pseudomallei." Nature Reviews Microbiology 4.4 (2006): 272-282.
2. Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management.
Clin Microbiol Rev 2005;18:383-416.
3. Poe RH, Vassallo CL, Domm BM. Melioidosis: the remarkable imitator. Am Rev Respir
Dis 1971;104:427-31.
4. Vidyalakshmi K, Shrikala B, Bharathi B, Suchitra U. Melioidosis: an under-diagnosed
entity in western coastal India: a clinico-microbiological analysis. Indian J Med
Microbiol 2007;25:245-8.
5. Saravu K, Mukhopadhyay C, Vishwanath S, Valsalan R, Docherla M, Vandana KE, et al.
Melioidosis in southern India: epidemiological and clinical profile. Southeast Asian J
Trop Med Public Health 2010;41:401-9.


Lakshay Chanana
Twitter: @EMDidactic
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