melioidosis , though endemic in the southeast asian regions , such as thailand , singapore malaysia and australia , was also reported from africa , north and south america , pacific and caribbean islands , middle east and europe . in india , it is more prevalent in the south ; though also reported from other parts . the disease is underreported due to its protean manifestations and low physician index of suspicion . many laboratories relying on conventional culture methods confuse it with pseudomonas species due to common phenotypic characteristics . john et al reported that the disease could be more prevalent than what is available in literature . we report two who were undiagnosed initially and presented to us within 3 months of each other . both belonged to madhubani district in bihar , raising possibilities that the area could be endemic for the disease . a 65-year - old male presented with fever , cough with breathlessness for last 2 months , alongwith swelling , redness and pain affecting both ankles for 7 days . two months earlier , he was treated for clinically suspected typhoid with no resolution of the fever . at the same time body temperature was 101 f , bp was 90/70 mmhg , respiratory rate 50/min , heart rate 128/minute . investigations showed a total leukocyte count ( tlc ) of 24,000/mm , the peripheral blood smear revealedtoxic granulations and vacuolations , the liver enzymes wereraised with the values of aspartate aminotransferase ( sgot)- 160 iu / l , alanine aminotransferase ( sgpt)- 82 iu / l , alkaline phosphatase ( alp)- 1120 iu / l , g - glutamyl transferase ( ggt)- 216 iu / l , lactate dehydrogenase ( ldh )  387 iu / l . , a chest x - ray showed homogenous consolidation on theleft side , an ultrasound showed bilateral pleural effusions and mild ascitis ; high sensitivity c - reactive protein ( hs crp ) level was 233.8 mg / dl , procalcitonin level was 0.5 ng / ml , glycosylated hemoglobin ( hba1c ) level was high at 11.10% , acid - fast stain ( afb ) from sputum carried out for 3 days , malarial antigen , widal test , urine culture were all negative . he was ventilated and based on a clinical diagnosis of sepsis , started on an empirical therapy with piperacillin / tazobactum and clindamycin . he continued to be febrile and on day 3 , right ankle was surgically drained and pus collected for culture . blood culture put up in the fully automated bactec ( beckton and dickinson ) showed positivity on the third day and grew nonfermenting , oxidase - positive flat , dry , wrinkled colonies which were subsequently identified as burkholderia pseudomallei in microscan 96 si ( siemens , frimley , camberley , uk ) . burkholderia pseudomallei was alsoisolated from his endotracheal secretions and pus . a 58-year - old male presented with fever ( on and off from last 1 to 11/2 years ) , cough , pain and swelling of left knee for last 2 weeks . he was a known diabetic for last few years . on presentation , his temperature was 100 f , pulse 90/minute ; blood pressure 94/50 mmhg , respiratory rate 38/minute . left knee was hot and tender ; however , anx - ray of the knee was normal . oxygen saturation was 80% for which he was started on non - invasive ventilator support . investigations showed a tlc of 10,900/cubic mm , the liver enzymes were raised with values of sgot- 117 iu / l , sgpt- 175 iu / l , alp- 69 iu / l , ggt  81 iu / l , ldh- 289 iu / l . hscrp level was 166.7 mg / dl , procalcitonin level was 0.9 ng / ml . hb a1 c level was 10.0% . sputum for afb ( stain and culture ) , malaria antigen test and widal test were all negative . blood cultures were sent from two different peripheral sites on the day of admission . on day 3 of admission , he had spikes of fever . burkholderia pseudomallei was isolated from all these blood samples . both the strains were resistant to ceftazidime ( mic>32 mg / l ) and sensitive to imipenem ( mic < 2 mg / l ) , co - trimoxazole ( mic < 1/19 mg / l)and tetracycline ( mic < 2 mg / l ) . antibiotics were escalated to imipenem ( 50 mg / kg / day ) in both cases . both cases responded well and were discharged on maintenance therapy with co - trimoxazole and doxycycline for 20 weeks . a 65-year - old male presented with fever , cough with breathlessness for last 2 months , alongwith swelling , redness and pain affecting both ankles for 7 days . two months earlier , he was treated for clinically suspected typhoid with no resolution of the fever . at the same time body temperature was 101 f , bp was 90/70 mmhg , respiratory rate 50/min , heart rate 128/minute . investigations showed a total leukocyte count ( tlc ) of 24,000/mm , the peripheral blood smear revealedtoxic granulations and vacuolations , the liver enzymes wereraised with the values of aspartate aminotransferase ( sgot)- 160 iu / l , alanine aminotransferase ( sgpt)- 82 iu / l , alkaline phosphatase ( alp)- 1120 iu / l , g - glutamyl transferase ( ggt)- 216 iu / l , lactate dehydrogenase ( ldh )  387 iu / l . , a chest x - ray showed homogenous consolidation on theleft side , an ultrasound showed bilateral pleural effusions and mild ascitis ; high sensitivity c - reactive protein ( hs crp ) level was 233.8 mg / dl , procalcitonin level was 0.5 ng / ml , glycosylated hemoglobin ( hba1c ) level was high at 11.10% , acid - fast stain ( afb ) from sputum carried out for 3 days , malarial antigen , widal test , urine culture were all negative . he was ventilated and based on a clinical diagnosis of sepsis , started on an empirical therapy with piperacillin / tazobactum and clindamycin . he continued to be febrile and on day 3 , right ankle was surgically drained and pus collected for culture . blood culture put up in the fully automated bactec ( beckton and dickinson ) showed positivity on the third day and grew nonfermenting , oxidase - positive flat , dry , wrinkled colonies which were subsequently identified as burkholderia pseudomallei in microscan 96 si ( siemens , frimley , camberley , uk ) . a 58-year - old male presented with fever ( on and off from last 1 to 11/2 years ) , cough , pain and swelling of left knee for last 2 weeks . he was a known diabetic for last few years . on presentation , his temperature was 100 f , pulse 90/minute ; blood pressure 94/50 mmhg , respiratory rate 38/minute . left knee was hot and tender ; however , anx - ray of the knee was normal . oxygen saturation was 80% for which he was started on non - invasive ventilator support . investigations showed a tlc of 10,900/cubic mm , the liver enzymes were raised with values of sgot- 117 iu / l , sgpt- 175 iu / l , alp- 69 iu / l , ggt  81 iu / l , ldh- 289 iu / l . hscrp level was 166.7 mg / dl , procalcitonin level was 0.9 ng / ml . hb a1 c level was 10.0% . sputum for afb ( stain and culture ) , malaria antigen test and widal test were all negative . blood cultures were sent from two different peripheral sites on the day of admission . on day 3 of admission , he had spikes of fever . burkholderia pseudomallei was isolated from all these blood samples . both the strains were resistant to ceftazidime ( mic>32 mg / l ) and sensitive to imipenem ( mic < 2 mg / l ) , co - trimoxazole ( mic < 1/19 mg / l)and tetracycline ( mic < 2 mg / l ) . antibiotics were escalated to imipenem ( 50 mg / kg / day ) in both cases . both cases responded well and were discharged on maintenance therapy with co - trimoxazole and doxycycline for 20 weeks . it is an emerging infectionin india with the first case reported in a child from dapoli in maharashtra in 1990 . it is reported also from kerela , karnataka , east , northeast and the south east . found fever to be the commonest complaint ( 96% cases ) and diabetes mellitus as a predisposing factor which we found in both our cases . the second case had a long history of fever attributable to the chronic form of melioidosis . burkholderia pseudomallei is present as an environmental saprophyte in soil and fresh surface water in endemic regions ; posing a high risk of infection to this group of people . lack of clinical know - how of this disease and insufficient laboratory expertise usually hamper the diagnosis of the disease . further epidemiological studies are indicated to determine the geographical prevelance and risk factors of this condition .