Abstract
Melioidosis, caused by Burkholderia pseudomallei, is an under-diagnosed tropical infection that often mimics tuberculosis and other chest diseases. We report the case of a 42-year old diabetic female who presented with fever and pneumonia and who developed septic arthritis. Blood, joint fluid, and abscess cultures grew B. pseudomallei. Initial treatment was with meropenem but owing to a suboptimal response, the patient was changed to a combination therapy with ceftazidime which led to clinical and biochemical improvement. She was then discharged with a three month course of co-trimoxazole for eradication. This case illustrates the multifocal nature of melioidosis and the diagnostic challenges even in endemic areas, emphasizing the need for high clinical suspicion as well as the need for prompt and aggressive antimicrobial therapy for optimal outcome.
Case report
A 42-year
On admission she was febrile (39.4 °C), tachycardic (126/min), tachypnoeic (38/min) and hyperglycaemic (capillary glucose 33.4 mmol/L), requiring intensive care and insulin infusion. She had bronchial breathing in the left anterior and infra-axillary thorax, bilateral crackles, wheeze, and a soft erythematous tender swelling on the right thigh.
A chest radiograph showed bilateral patchy opacities consistent with bronchopneumonia (Image 1). Initial laboratory results showed an anaemia (Hb 92 g/L), normal white count (5.6 × 10⁹/L), but markedly elevated inflammatory markers (ESR 130 mm/h, ferritin 1006 μg/mL, D-dimer 6138 mg/L).
Chest radiograph showing bilateral patchy air-space opacities, more pronounced in the middle and lower zones, consistent with bronchopneumonia.
Empirical meropenem was started and investigations to rule out tuberculosis reactivation were done including Sputum AFB and CBNAAT which were negative. Bronchoscopy showed mild mucosal inflammation and increased secretions; broncho-alveolar lavage was performed and was negative for acid-fast bacilli. Voriconazole was added for suspected fungal co-infection. However three days after admission, she developed left elbow pain and swelling. A joint radiograph and ultrasound scan confirmed arthritis. Ultrasound-guided joint aspiration and blood cultures grew B. pseudomallei, confirming multifocal melioidosis.
Owing to poor response to meropenem monotherapy, intravenous ceftazidime was added and this resulted in significant clinical improvement (Image 2). After two weeks, she could be discharged with a three month course of oral co-trimoxazole for eradication therapy.
Chest radiograph showing clearing of prior air-space opacities, indicating radiologic improvement after antibiotic course.
Discussion
Melioidosis is endemic across tropical regions and is strongly associated with diabetes and other immuno-compromising conditions; it commonly presents as pneumonia with clinical and radiological findings mimicking tuberculosis.1–3 Although bone and joint involvement is known, it is a less frequently reported entity and has multifocal presentations leading to delay in diagnosis. 4
Early recognition and aggressive antibiotic therapy remain crucial for favorable outcomes. In our case, meropenem monotherapy was insufficient, and the addition of ceftazidime coincided with rapid improvement. We acknowledge the limits of inference from one case, but the temporal association suggests that combination therapy may be beneficial in selected cases of disseminated melioidosis, and this warrants further studies.
Footnotes
Acknowledgements
We would like to acknowledge Dr Navein Thomas for his expert diagnostic input and for providing critical guidance during the preparation and submission of this case report.
Ethical considerations
All efforts have been made to ensure patient privacy and confidentiality. Potential identifiers have been removed or anonymized.
Consent to participate
Not applicable.
Consent for publication
Informed consent for publication of identifiable information and imaging was obtained from the patient.
Author contributions
Dr Amal Joseph: conceptualization, investigation, writing—original draft. Dr Anna Carin Sunil: drafting, data curation. Dr Devapriya Manazhy: supervision, review. Dr Merlin Elizabeth Thomas: project administration, supervision, review & editing.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
Not applicable.