| Abstract|| |
Burkholderia pseudomallei, a Gram-negative bacillus is the causative agent of Melioidosis, a glanders-like disease, primarily a disease of animals. Melioidosis has been only a rare and sporadic disease in humans outside its endemic region. Currently, diagnosis of B. pseudomallei in the clinical laboratory is very difficult, owing to low awareness of physicians to the nonspecific clinical manifestations, lack of responsiveness among microbiologists outside endemic areas, identification systems in the average sentinel laboratory, and the biosafety conditions necessary to process these organisms. We report a case of chronic left hip joint effusion in a known case of diabetes mellitus. Gram stain of computed tomography (CT)-guided aspirate from the joint revealed Gram-negative bacilli along with pus cells. Culture was confirmed as Burkholderia pseudomallei on Vitek2C, which was sensitive to ceftazidime and trimethoprim/sulfmethoxazole. Unfortunately, patient could not be started on appropriate antibiotics due to delay in detection and patient succumbed to severe septicemia. This case is reported to highlight importance of automated identification and sensitivity especially in nonendemic areas and unusual antibiogram of this organism for which disc diffusion method is not standardized.
Keywords: Burkholderia pseudomallei , Melioidosis, non-endemic region, automated identification and sensitivity
|How to cite this article:|
Deshmukh M, Mundhada S. Chronic suppurative joint effusion due to burkholderia pseudomallei: A case report. Indian J Pathol Microbiol 2013;56:460-3
|How to cite this URL:|
Deshmukh M, Mundhada S. Chronic suppurative joint effusion due to burkholderia pseudomallei: A case report. Indian J Pathol Microbiol [serial online] 2013 [cited 2020 Feb 24];56:460-3. Available from: http://www.ijpmonline.org/text.asp?2013/56/4/460/125373
| Introduction|| |
Burkholderia pseudomallei is the causative agent of melioidosis, primarily a disease of animals such as sheep, goats, cattle, swine, and horses. Melioidosis, also known as Whitmore disease, is endemic in China, Thailand, Malaysia, Singapore, Vietnam, and northern Australia. , Despite similar environmental conditions, very few cases of melioidosis are reported from the Indian subcontinent. Melioidosis and Glanders (caused by Burkholderia mallei) are of interest because of significant study for potential weaponization by the United States and other countries in the past. Both organisms are considered potential biological warfare (BW) agents, especially in the aerosolized form. In fact, because of the fact that they are highly infectious especially by inhalation and because of their resistance to routine antibiotics, both bacteria have been classified as category B priority pathogens by the National Institutes of Health and the Centers for Disease Control and Prevention. 
Melioidosis has been only a rare and sporadic disease in humans outside its endemic region. Humans and animals are believed to acquire the infection by inhalation of contaminated dust or water droplets, ingestion of contaminated water, and contact with contaminated soil especially through skin abrasions.  Human cases of melioidosis have also occurred from sexual contact and intravenous drug use. It has been observed in immigrants, military personnel, and travelers. 
Burkholderia pseudomallei is a motile, aerobic, nonspore-forming bacillus. It is clinically similar to Glanders disease. The incubation period is not clearly defined, but may range from one day to many years; generally symptoms appear 2-4 weeks after exposure.  It has an ability to produce latent infection that can reactivate many years later after primary exposure; hence also nicknamed as Vietnamese Time Bomb. There are four types of presentations of B. pseudomallei ranging from acute localized form, chronic form, pulmonary form, and acute bloodstream form. Acute localized infection generally presents as localized abscess or nodule may be associated with fever, general muscle ache, and may progress rapidly to affect bloodstream. Pulmonary form presents as mild bronchitis to severe pneumonia. Productive or nonproductive cough with normal sputum is hallmark of this form of melioidosis. Fulminant septic form affects multiple systems and pus filled lesions and abscesses on the skin and throughout the body. ,, Immunosuppressed status and diabetes particularly favor systematic spread. Septicemia may be overwhelming, with 90% fatality rate and death occurring within 24-48 hours. Chronic suppurative infection appears after variable incubation period as multiple abscesses affecting various organs typically joints, liver, spleen, lymph nodes, skin, brain, etc. , Untreated patients with septicemia have fatal outcomes. It is greater than 50% for septicemic disease and 20% for localized disease despite treatment. Overall, the mortality rate is 40%.  There is nothing specific about this disease hence also dubbed as a great mimicker; and a strong clinical suspicion is required especially due to its high mortality in any form and distinctive antibiotic sensitivity pattern.
| Case Report|| |
A 43-year-old male farmer, a known case of diabetes, was admitted to a tertiary care centre with H/o difficulty in walking and inability to bear weight since 8-10 days, left sided backache, and hip joint pain since 8-10 days, fever with chills since 8 days. On admission, patient was conscious, oriented with nagging left sided backache. Investigations revealed leucocytosis (TLC 12,200/mm 3 ), marginally raised hepatic enzymes. Ultrasound (USG) abdomen revealed hepatosplenomegaly. CVS- S1 S2 was normal with no murmur. RS- chest was clear. P/A- soft with mild rigidity in the right hypochondriac region, mild left leg oedema. Emperic antibiotic treatment with IV fluoroquinolones, cephalosporins, and antimalarials was started. All fever profiles, that is, Widal, Leptospira antibodies, viral profile, blood cultures, PS for MP were negative. In view of low backache, magnetic resonance imaging (MRI) for spine and left hip was done, which showed minimal left hip joint effusion causing mild posterior bulge at lumbosacral region causing anterior thecal sac compression. HLA B27 and ANA profile were negative. Fever was still persistent after 8 days of admission; hence antibiotics were escalated to piperacillin-tazobactum, meropenem, and vancomycin. Blood cultures were still negative.
With persistent left hip joint pain and difficulty, arthrotomy was done to remove around 10-15 cc of pus. Bacteriological culture was negative but DNA TB polymerase chain reaction (PCR) was positive. As patient was not responding to above mentioned antibiotics, antitubercular treatment was initiated. After initial brief improvement, patient again deteriorated clinically. Increase in TLC to 25,000/mm 3 , raised CRP and high procalcitonin levels (>2) suggested impending septicemia and patient was shifted to intensive care unit (ICU) on day 21.
Follow-up MRI showed mild reduction in hip joint effusion. But with worsening of the patient, whole computed tomography (CT) chest and abdomen was done, which showed multiple nodular lung lesions. Loculated collection around left femoral neck, which was removed (approximately 40-50 ml) and sent for automated bacteriological culture. Antibiotics were escalated to colistin, meropenem, and daptomycin. Blood cultures were still negative. Unfortunately, patient succumbed 2 days later despite all resuscitative measures. Meanwhile, gram stain of collection from left thigh showed Gram-negative bacilli. Burkholderia pseudomallei was isolated with 95% confidence level on Vitek 2C after 48 hours of incubation [Table 1], which was resistant to aminoglycosides and colistin; sensitive to trimethoprim/sulfamethoxazole, ceftazidime, ceftriaxone (drugs of choice for melioidosis ) [Table 2]. These were unfortunately missing in patient's treatment regimen.
|Table 1. Biochemical reacti ons separati ng Burkholderia pseudomallei rom Pseudomonas aeruginosa|
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Microbiological work up done
Gram stain: Pus cells seen. Gram-negative bacilli seen.
Blood agar and Chocolate agar: Nonhemolytic, dry, wrinkled colonies [Figure 1].
|Figure 1: Chocolate Agar showing pale, dry, wrinkled colonies aft er 24 hours of incubation|
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Mac Conkey Agar: Nonlactose fermenting colonies.
Oxidase test: Positive
GN ID card: Identified B. pseudomallei with 95% confidence level.
| Discussion|| |
A strong clinical suspicion is required to assist in making a diagnosis especially in nonendemic regions due to its vague clinical presentation. This is particularly true for patients with predisposing comorbidities and immunosuppressed status like diabetes mellitus, chronic renal failure, alcoholism, or malignancy and those living in or with a history of travel to endemic areas. However, the above subsets of patients will be the most affected in the event of an intentional bacteriological attack in other regions of the world and increased international travel. 
Laboratory confirmation is necessary to diagnose melioidosis. On Gram stain, B. pseudomallei may be seen as Gram negative rods and safety-pin appearance on methylene blue stain. Isolation of B. pseudomallei by culture from a clinical specimen is the gold standard for diagnosis.  Organisms grow well on most of the culture media routinely used in the microbiology laboratories. When grown on blood agar, they grow as dry wrinkled colonies (resembling Pseudomonas stutzeri). Ashdown media, which contains various dyes and gentamicin, is a selective media for B. pseudomallei, which shows dry wrinkled colonies with metallic sheen, may be used in endemic areas for earlier diagnosis.
Though initially included in the genus Pseudomonas; based upon genomic studies separated into separate Burkholderia genus. But they still share many properties with the original genus like oxidase positivity. Many microbiologists are unfamiliar with B. pseudomallei and as a result it has frequently been misidentified as Pseudomonas species or as a contaminant in a culture.  In nonendemic region, particularly due to lack of awareness on the part of clinicians as well as microbiologists, automated systems play a vital role in correct identification.
Very limited data is available about in vitro sensitivity of the organism and there are no validated testing methods available. But the unusual antibiogram (i.e., aminoglycoside and colistin resistant and ceftazidime, amoxicillin-clavulanic sensitive) in an oxidase positive gram negative rod should raise an eye brow in the microbiology laboratory. Till then, automated system should guide the clinicians about antibiotic profile and emergence of resistance in the backdrop of prolonged treatment needed for eradication of this bacillus.
Serological tests are helpful in making a provisional diagnosis in the absence of isolation of B. pseudomallei in the specimen. Slide agglutination test, indirect hemagglutination test, complement fixation tests are some of the tests used for diagnosis of melioidosis. Enzyme linked immunosorbent assay (ELISA) detecting specific IgG and IgM antibodies is recommended as a diagnostic serological test when melioidosis is in the differential diagnosis of Pyrexia of unknown (PUO) cases. ,
During the past decade, many efforts have been made to develop new molecular procedures to identify B. pseudomallei from various specimens. Molecular biology techniques such as PCR, dot immunoassay, pulsed field gel electrophoresis (PFGE), restricted fragmentation length polymorphism (RFLP), and random amplification of particle of deoxyribonulease (RAPD) are also used for diagnosis. These are the recommended techniques for the rapid diagnosis of the disease and for monitoring therapy and epidemiological studies because of its high sensitivity, specificity, simplicity, and speed. 
Limited information exists about antibiotic therapy in humans because studies examining antibiotic effectiveness in vivo are rare. Ceftazidime is the drug of choice in systemic melioidosis. Ceftazidime (120 mg/kg/day), has shown to reduce the mortality significantly in severe melioidosis.  However, resistant strains are beginning to appear.  Carbapenems are also suitable for the treatment of the disease. , A study showed that meropenem [1 g or 25 mg/kg, 8 hourly intravenously for 14 days] can be considered as an alternative to ceftazidime and imipenem in the treatment of melioidosis, but this is more expensive and more trials are required.  Doxycycline can be used in localized infections in combination with cotrimoxazole.  Following the treatment of the acute disease, it is recommended that eradication (or maintenance) treatment with co-trimoxazole and doxycycline be used for 12-20 weeks to reduce the rate of recurrence. , Recurrence occurs in 10-20% of patients. The type of infection and the course of treatment will impact long-term outcome.
There is currently no licensed vaccine available for protection against melioidosis. At present, studies are underway to identify possible antigens using lipopolysacchrides of B. pseudomallei in mouse models. 
Attention should be paid to a history of travel to endemic areas in returned traveler s. Melioidosis should be differentiated from bacterial pneumonia, plague andatypical pneumonia-viral, mycoplasma, anthrax, etc. A definite history of contact with soil may not be elicited as melioidosis can be dormant for many years before manifesting. 
Melioidosis is majorly an emerging global disease. Even though very scarcely reported from India, it might be just the tip of iceberg we are sitting on in view of similar environmental and epidemiological conditions required for B. pseudomallei infection. High degree of suspicion in all the PUO cases by the clinicians and alertness on the part of microbiologists should guide us through exact incidence of this disease. It will also be useful for initiation of appropriate antibiotics as it is resistant to the more traditional antimicrobial regimens and also due to the need for long-term suppressive therapy to prevent relapse.
| Acknowledgment|| |
The authors thank Dr. Jay M. Deshmukh, Dr. Tushar Pande, and Dr. Ashish Gaanjare for their contribution for their clinical inputs. The authors thank Ms. Anagha Bhusari, Mr. Lucky Thakkar, Ms. Mayuri Patne for help in laboratory work.
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Dhruv Pathology and Molecular Diagnostic Lab, Aditya Enclave, 20A Central Bazar Road, Ramdaspeth, Nagpur - 440 010, Maharashtra
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]