Reactivation of latent melioidosis presenting with acute pyelonephritis and bacteremia
The present case report is about an 81-year-old Indian male patient who presented to the emergency room with the complaining of worsening fevers, chills, dysuria and decreased appetite over a 3-week period. His medical history included diabetes mellitus, chronic obstructive pulmonary disease, hypertension, benign prostatic hyperplasia and dyslipidemia. His surgical history was unremarkable and he was taking atenolol and lovastatin as an out-patient. He reported that he had been to the emergency room 1 month ago for the treatment and management of lower gastrointestinal bleed secondary to colitis. During that admission, he developed a urinary tract infection for which he was treated with oral levofloxacin as an out-patient. He denied any history of smoking. He also denied any illicit drug or alcohol use. The patient emigrated from India to the United States of America (USA) over 40 years ago. The last time he travelled out of the USA was to India 2 years ago. His symptoms began approximately 3 weeks prior. On admission, he was febrile, with a temperature of 102°F. He was hemodynamically stable, but in obvious discomfort complaining of weakness and dizziness. On physical examination, he had suprapubic tenderness and right cost overtebral/flank tenderness, but no other physical abnormalities. His prostate exam was unremarkable. Initial laboratory work-up revealed an elevated leukocyte count of 13 × 103 with a left shift. His urine analysis revealed 10-15 red blood cells per high power field, 50 leukocytes per high-power field, positive bacteria with positive nitrates and leukocyte esterase and few hyaline casts. A chest X-ray was unremarkable, but a computed tomography scan of the abdomen and pelvis [] revealed wedge-shaped enhancement defects in the right kidney suggestive of pyelonephritis. We drew blood and urine cultures which both grew non-lactose fermenting, aerobic and motile Gram-negative rods which were identified to be B. pseudomallei. The patient was treated with a 2-week course of imipenem/cilastatin, followed by oral trimethoprim-sulfamethoxazole for eradication therapy for 4 months. As the result of the treatment regimen, the patient clinically improved and he was asymptomatic at the 4 months follow-up.