Melioidosis

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Abstract

Melioidosis is a disease endemic to India but often goes unrecognized, leading to considerable illness and death. We present the case of a 31-year-old man who had a fever of unknown origin, abnormal renal and liver function tests, and negative tests for dengue, typhoid, leptospirosis, and scrub typhus. Imaging revealed multiple splenic infarcts. Initially suspected to be malaria due to its prevalence in South India, further investigation uncovered pneumonia along with several liver and splenic abscesses, raising the possibility of melioidosis. Blood culture eventually identified Burkholderia pseudomallei, confirming the diagnosis. As malaria cases decline in Southeast Asia, emergency physicians should consider melioidosis in their differential diagnosis of acute febrile illnesses, especially in endemic areas. Early detection and prompt antibiotic treatment are vital for managing this often under-recognized disease with a high fatality rate. Thus, melioidosis should be considered in patients with unexplained fever in endemic regions, as early diagnosis and intervention can be life-saving.

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Most cited references 16

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W. Joost Wiersinga, Direk Limmathurotsakul, David Dance … (2018)

Burkholderia pseudomallei is a Gram-negative environmental bacterium and the aetiological agent of melioidosis, a life-threatening infection that is estimated to account for ~89,000 deaths per year worldwide. Diabetes mellitus is a major risk factor for melioidosis, and the global diabetes pandemic could increase the number of fatalities caused by melioidosis. Melioidosis is endemic across tropical areas, especially in southeast Asia and northern Australia. Disease manifestations can range from acute septicaemia to chronic infection, as the facultative intracellular lifestyle and virulence factors of B. pseudomallei promote survival and persistence of the pathogen within a broad range of cells, and the bacteria can manipulate the host’s immune responses and signalling pathways to escape surveillance. The majority of patients present with sepsis, but specific clinical presentations and their severity vary depending on the route of bacterial entry (skin penetration, inhalation or ingestion), host immune function and bacterial strain and load. Diagnosis is based on clinical and epidemiological features as well as bacterial culture. Treatment requires long-term intravenous and oral antibiotic courses. Delays in treatment due to difficulties in clinical recognition and laboratory diagnosis often lead to poor outcomes and mortality can exceed 40% in some regions. Research into B. pseudomallei is increasing, owing to the biothreat potential of this pathogen and increasing awareness of the disease and its burden; however, better diagnostic tests are needed to improve early confirmation of diagnosis, which would enable better therapeutic efficacy and survival.

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Predicted global distribution of Burkholderia pseudomallei and burden of melioidosis.

David Dance, Eric Bertherat, David M. Pigott … (2016)

Burkholderia pseudomallei, a highly pathogenic bacterium that causes melioidosis, is commonly found in soil in Southeast Asia and Northern Australia(1,2). Melioidosis can be difficult to diagnose due to its diverse clinical manifestations and the inadequacy of conventional bacterial identification methods(3). The bacterium is intrinsically resistant to a wide range of antimicrobials, and treatment with ineffective antimicrobials may result in case fatality rates (CFRs) exceeding 70%(4,5). The importation of infected animals has, in the past, spread melioidosis to non-endemic areas(6,7). The global distribution of B. pseudomallei and the burden of melioidosis, however, remain poorly understood. Here, we map documented human and animal cases and the presence of environmental B. pseudomallei and combine this in a formal modelling framework(8-10) to estimate the global burden of melioidosis. We estimate there to be 165,000 (95% credible interval 68,000-412,000) human melioidosis cases per year worldwide, from which 89,000 (36,000-227,000) people die. Our estimates suggest that melioidosis is severely underreported in the 45 countries in which it is known to be endemic and that melioidosis is probably endemic in a further 34 countries that have never reported the disease. The large numbers of estimated cases and fatalities emphasize that the disease warrants renewed attention from public health officials and policy makers.

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Melioidosis: epidemiology, pathophysiology, and management.

Allen Cheng, Bart Currie (2005)

Melioidosis, caused by the gram-negative saprophyte Burkholderia pseudomallei, is a disease of public health importance in southeast Asia and northern Australia that is associated with high case-fatality rates in animals and humans. It has the potential for epidemic spread to areas where it is not endemic, and sporadic case reports elsewhere in the world suggest that as-yet-unrecognized foci of infection may exist. Environmental determinants of this infection, apart from a close association with rainfall, are yet to be elucidated. The sequencing of the genome of a strain of B. pseudomallei has recently been completed and will help in the further identification of virulence factors. The presence of specific risk factors for infection, such as diabetes, suggests that functional neutrophil defects are important in the pathogenesis of melioidosis; other studies have defined virulence factors (including a type III secretion system) that allow evasion of killing mechanisms by phagocytes. There is a possible role for cell-mediated immunity, but repeated environmental exposure does not elicit protective humoral or cellular immunity. A vaccine is under development, but economic constraints may make vaccination an unrealistic option for many regions of endemicity. Disease manifestations are protean, and no inexpensive, practical, and accurate rapid diagnostic tests are commercially available; diagnosis relies on culture of the organism. Despite the introduction of ceftazidime- and carbapenem-based intravenous treatments, melioidosis is still associated with a significant mortality attributable to severe sepsis and its complications. A long course of oral eradication therapy is required to prevent relapse. Studies exploring the role of preventative measures, earlier clinical identification, and better management of severe sepsis are required to reduce the burden of this disease.

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Author and article information

Journal

Journal ID (nlm-ta): Turk J Emerg Med

Journal ID (iso-abbrev): Turk J Emerg Med

Journal ID (publisher-id): TJEM

Journal ID (publisher-id): Turk J Emerg Med

Title: Turkish Journal of Emergency Medicine

Publisher: Wolters Kluwer - Medknow (India )

ISSN (Electronic): 2452-2473

Publication date Collection: Jan-Mar 2025

Publication date (Electronic): 02 January 2025

Volume: 25

Issue: 1

Pages: 63-66

Affiliations

[1] Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Author notes

[*]

Corresponding author

Author contributions statement

AM: Conceptualization (lead); Literature search (equal); data collection (lead); Writing – original draft (lead). BN: Conceptualization (support); Writing – review and editing (equal). AU: Data collection (equal); Writing – review and editing (equal). AD: Writing – review and editing (equal). SM: Data collection (equal); Writing – original draft (support).

BN takes responsibility for the paper as a whole.

Address for correspondence: Dr. Balamurugan Nathan, Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006, India. E-mail: murugan bala2006@ 123456gmail.com

Author information

Anas Mohammed Muthanikkatt https://orcid.org/0000-0003-2325-4719

Balamurugan Nathan https://orcid.org/0000-0002-3286-7034

Amaravathi Uthayakumar https://orcid.org/0000-0003-0849-3447

Anandhi Devendiran https://orcid.org/0000-0003-3498-6392

Saravanan Muthu https://orcid.org/0000-0002-3286-7034

Article

Publisher ID: TJEM-25-63

DOI: 10.4103/tjem.tjem_62_24

PMC ID: 11774432

PubMed ID: 39882094

SO-VID: e99bde3e-1016-4bb6-b663-667097528f9e

License:

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

History

Date received : 29 March 2024

Date revision received : 12 September 2024

Date accepted : 15 September 2024

Funding

None.

Melioidosis – An under-recognized dreaded disease in Southeast Asia

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