Acute pulmonary melioidosis in a child: A case report and review of literature
A 16-month-old girl child from North east district of India presented to the emergency department with multiple erythematous nodules and ulcers in the skin [Figure and ], difficulty in breathing, and fever since 5 days. The parents gave history of near drowning in drain water 7 days prior to the onset of illness. The birth history was unremarkable.\nOn general physical examination, the child was conscious, irritable, febrile with toxic look, had tachypnea and tachycardia, and weighed 8 kg (Grade I malnutrition for age). Multiple erythematous nodules and ulcers (ecthyma gangrenosum) were noted in the skin, with few eschars [Figure and ]. Her pulse was 100/min and BP 90/56 mm Hg. Routine blood examinations revealed raised leukocyte count (14,500/mm3), neutrophilia (89%), elevated C-reactive protein (CRP; 68 mg/l) and procalcitonin (2.56 ng/dl) levels. The liver enzymes were mildly elevated [aspartate transaminase (AST) 138 IU/l; alanine transaminase (ALT) 99 IU/l; alkaline phosphatase (ALP) 363 IU/l] and renal function tests were unremarkable. The blood sugar level was within normal limits. ELISA test for the qualitative determination of antibodies to human immunodeficiency virus (HIV) type 1 and 2 viruses was non reactive. On examining the respiratory system, coarse crepitations and rhonchi were noted bilaterally.\nInitial empirical antibiotic therapy was initiated with intravenous (IV) injections of Piperacillin + Tazobactum and Netilmicin. However, there was progressive deterioration of the patient's general condition with appearance of new skin lesions during the course of treatment.\nAn anterior–posterior (AP) view of chest radiograph [] revealed multiple patchy consolidations with air bronchogram in the left upper-mid zone and right mid and lower zones, with cavitations in few of them.\nHigh-resolution computed tomography (HRCT) and contrast-enhanced computed tomography (CECT) of the thorax was done on 64 slice MDCT scanner, (Aquilion 64, Toshiba Medical Systems Corporation, Japan) [Figures –] which revealed multiple variable-sized segmental and subsegmental air-space consolidations scattered in bilateral lung parenchyma, more on the right side where few of them showed areas of eccentrically located breakdown and cavitations. Multiple relatively larger nodular lesions were also noted in parenchyma of both the lungs. Most of the cavitary lesions showed dependant intracavitary low-density collections. No mediastinal lymphadenopathy was noted. Based on the imaging findings, an initial diagnosis of septic pyogenic pneumonic abscesses with differential diagnosis of pulmonary tuberculosis was given.\nHowever, a diagnosis of tuberculosis did not correlate well with the atypical skin lesions, the acute presentation, and the rapidly progressing clinical deterioration of the child. A fine-needle aspiration cytology (FNAC) from a nodule in the left forearm revealed frank pus [Figures and ]. A blood culture was done which showed growth of colonies of B. pseudomallei within 3 days, which established the diagnosis of melioidosis.\nBased on the culture and sensitivity reports, specific antibiotic therapy was started with IV Meropenam, along with nebulization. However, despite intensive care and antibiotic therapy unfortunately, the child died 2 days later due to septicemic pneumonia (1 week since admission).