Clinically lesser known entity in India: A Report of two cases of Melioidosis
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 he was also found to be diabetic. Atpresentation, patient was toxic, febrile, icteric and dehydrated. Body temperature was 101 °F, BP was 90/70 mmHg, respiratory rate 50/min, heart rate 128/minute. Bronchial breath sounds were heard on the left side and bilateral crackles were present. Spleen was mildly enlarged. Both ankles were erythemic and edematous. The right foot was affected by cellulitis with purulent discharge. Investigations showed a total leukocyte count (TLC) of 24,000/mm3, 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. Blood from two different peripheral sites and endotracheal secretions were sent for culture. Arterial blood gases showed a hypoxic state With an oxygen saturation at 78%. 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).\nBurkholderia pseudomallei was alsoisolated from his endotracheal secretions and pus.