melioidosis is predominantly a tropical disease and most cases are reported during the rainy season in endemic area .
it is characterized by abscess - formation in the lung , liver , spleen , skeletal muscle and prostate with the lung being the most commonly involved organ .
the clinical features are variable from rapidly progressing septicemia to chronic debilitating abscess - forming disease .
understanding about melioidosis is important in tuberculosis endemic areas , because its progression and roentgenographic findings are so similar to tuberculosis that it is not rare for melioidosis to be misdiagnosed as tuberculosis .
the patient was a 50-yr - old man who was diagnosed with melioidosis on bronchoscopic washing culture and whose symptoms improved after treatment with high dose ceftazidime .
a 50-yr - old man visited our hospital because of intermittent fever associated with cough , sputum , generalized myalgia and general weakness for about four weeks .
he had lived in indonesia for twenty years for business , and visited a local hospital in indonesia and was treated for typhoid fever without improvement of symptoms .
initial chest radiograph and computed tomography ( ct ) images showed multiple satellite nodules in the left lower and upper lobes , and judging from that roentgenographic examination , tuberculosis was the most probable diagnosis ( fig .
1 ) . bronchoscopy showed no endobronchial lesion and washing cytology and culture were also negative .
three months later we rechecked chest radiograph and ct findings , and found new infiltration in the left lower lobe and improvement of lesions in the left upper and lower lobes ( fig .
laboratory findings included white blood cell count of 5,240/l and hemoglobin value of 11.6 g / dl .
iga was 227 mg / dl ( normal range : 90 - 400 mg / dl ) and anti - neutrophilic cytoplasmic antibodies with cytoplasmic staining pattern ( canca ) was negative .
however , secretion was seen in left lower lobe , so washing cytology and culture was done .
cytology was negative but a species of bacteria grew on blood agar media ( fig .
3 ) . it was gram - negative , non - spore forming and showed as a safety pin shaped organism on microscopic examination ( fig .
api20ne strip and vitek gni card ( biomerieux , inc . , hazelwood , u.s.a . ) ,
the organism was identified as burkholderia pseudomallei ( 1 ) . on dna sequencing of 16s ribosomal rna , it was compatible with b. pseudomallei with 100% homology and formed a characteristic rugose colony on blood agar .
we prescribed ceftazidime 2 g intravenously every 8 hr and he did not complain of intermittent fever any more .
after one week of intravenous ceftazidime , he was discharged with oral amoxicillin - clavulanate ( 750 mg every 8 hr ) .
one month later the cough and sputum were almost disappeared but his general weakness persisted although it was also improving .
four months later we rechecked chest ct to show an improvement of infiltration in left lower lobe .
he said his condition was as good as his previous state before suffering from melioidosis .
one month later , we stopped administrating oral antibiotics to him , which resulted in him taking amoxicillin - clavulanate for total five months .
the endemic area includes southeast asia , north australia , madagascar , and guam ( 2 ) . in northeast
thailand , melioidosis accounts for 20% of all community - acquired septicemias , and causes death in 40% of treated patients .
melioidosis was first described by whitmore in 1911 and more than 100 cases had been reported by 1917 ( 3 ) . since then , with sporadic cases being reported during and after world war ii and many soldiers fighting in vietnam suffering from this disease , western countries began to take an interest in melioidosis .
b. pseudomallei is a motile aerobic , non - spore - forming and gram - negative bacillus .
the colonies develop a rugose appearance , and take up crystal violet dye from the medium .
although it is gram - negative bacterium , it is usually resistant to aminoglycoside , 1st & 2nd cephalosporin , macrolide , rifamycin and colistin , but is susceptible to ampicillin / sulbactam , chloramphenicol , tetracycline , bactrim , 3rd cepha and carbapenem ( 4 ) .
b. pseudomallei is a soil saprophyte and can be recovered readily from water and wet soils in rice paddy fields .
for example , in thailand the organism can be cultured readily from more than 50% of rice paddies ( 5 ) .
it presents as a febrile illness , ranging from an acute fulminant sepsis to a chronic debilitating localized infection .
the lung is the most commonly affected organ , either presenting with cough and fever resulting from a primary lung abscess or pneumonia .
seeding and abscess formation can arise in any organ , and the liver , spleen , skeletal muscle and prostate are common sites .
localized pulmonary melioidosis often can not be differentiated from tuberculosis on clinical and chest radiography findings .
first , some melioidosis cases have rapid clinical and roentgenographic progression within a few days .
second , melioidosis usually responds to treatment well and has apparent roentgenographic improvement within 1 - 2 weeks .
third , parapneumonic effusion develops in 5 - 15% of cases , but the amount is not large and associated pulmonary infiltration is always present .
in contrast , tuberculosis pleurisy in which a large amount of pleural fluid is present without underlying pulmonary infiltration is common .
diagnosis of melioidosis is made by isolation of b. pseudomallei from any site ; for example blood , sputum , abscess fluid and throat swab .
since splenic abscess is much less common in other diseases , its presence is more likely to suggest melioidosis .
the antibiotic of choice is ceftazidime ( 40 mg / kg intravenous injection every 8 hr ) , while other 3rd generation cephalosporin is less effective ( 9 ) .
four - drug combination is usually recommended as oral antibiotics , and those are chloramphenicol ( 40 mg / kg per day in four divided doses ) , doxycycline ( 4 mg / kg per day in two divided doses ) , trimethoprim - sulfamethoxazole ( 10 mg and 50 mg / kg per day , respectively , in two divided doses ) .
high dose ceftazidime followed by long term oral antibiotics is considered to be most effective treatment .
the distribution and frequency of melioidosis is probably greatly underestimated ( 10 ) . in tuberculosis endemic areas ,
it is important to understand melioidosis and differentiate this disease from tuberculosis because the treatment of the two diseases is completely different .
 melioidosis is an infection of the gram - negative bacterium burkholderia pseudomallei . 
 while it is known as an important cause of sepsis or chronic abscess - forming disease in southeast asia and northern australia , no case has yet been reported in korea . 
 a 50-yr - old man visited our hospital for intermittent fever associated with dry cough and sputum . 
 roentgenographic examination showed migrating pulmonary infiltration . 
 symptoms and chest radiograph and computed tomography ( ct ) image findings did not improve despite use of fluoroquinolone antibiotics . 
 gram - negative bacteria were isolated on bronchoscopic washing culture and were identified as b. pseudomallei on dna sequencing of 16s ribosomal rna with 100% homology . 
 treatment for melioidosis was commenced with high dose ceftazidime , and the patient 's fever , cough , and sputum were improved and the lesion on chest radiograph and ct almost disappeared . 