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 ~  Abstract
 ~  Case Report
 ~  Discussion
 ~  Acknowledgements
 ~  References

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CASE REPORT
Year : 2003  |  Volume : 21  |  Issue : 2  |  Page : 129-132
 

Isolation of burkholderia pseudomallei from a case of septicaemia - A case report


Departments of Microbiology, Nizam's Institute of Medical Sciences Hyderabad - 500 082, India

Correspondence Address:
Departments of Microbiology, Nizam's Institute of Medical Sciences Hyderabad - 500 082, India

 ~ Abstract 

Meliodosis, an infectious disease caused by Burkholderia pseudomallei has been recognized as an emerging infectious disease in India. The infection is under diagnosed and underreported, and hence considered a rare disease. Majority of the cases have been documented from the states with heavy rainfall. The present case being reported is a middle-aged woman who had developed a fulminant infection following exposure to stagnant floodwater in the city of Hyderabad. To the best of our knowledge, this is the first case of Melioidosis being reported from this part of the country.

How to cite this article:
Anuradha K, Meena A K, Lakshmi V. Isolation of burkholderia pseudomallei from a case of septicaemia - A case report. Indian J Med Microbiol 2003;21:129-32


How to cite this URL:
Anuradha K, Meena A K, Lakshmi V. Isolation of burkholderia pseudomallei from a case of septicaemia - A case report. Indian J Med Microbiol [serial online] 2003 [cited 2019 Aug 23];21:129-32. Available from: http://www.ijmm.org/text.asp?2003/21/2/129/7992


Meliodosis, an infectious disease caused by Burkholderia pseudomallei has been recognized as an emerging infectious disease in India.[1] It is endemic in South East Asia and Northern Australia.[2] Due to the highly varied clinical presentation this infection is largely underdiagnosed in our country and also underreported which accounts for it to be rare in India.[1] Majority of the cases that have been documented are from the part of the country experiencing heavy rainfall. To the best of our knowledge, this is the first case of Melioidosis from south central India.

 ~ Case Report Top

A 45 year female patient, a resident of Hyderabad, was referred to our Institute with a history of fever, cough, vomiting, diarrhoea and altered sensorium of three days duration. The illness was preceded by contact with stagnant water during floods in Hyderabad. She was a known diabetic, on chlorformin and hypertensive on irregular treatment.
At the time of admission in our Institute, she was found to be a moderately built lady, febrile, unconscious with signs of meningeal irritation. Based on the clinical findings, a diagnosis of encephalitis and right lower lobe pneumonia with underlying non insulin dependant diabetes mellitus and hypertension was made. Further investigations showed an impending acute renal failure (blood urea 83mg% and creatinine 1.7mg%) and the coagulation profile was abnormally prolonged. The CSF analysis was normal. Febrile agglutinins (including Mycoplasma), HIV and autoimmune markers were negative. Arterial blood gases showed a hypoxic state. Electrocardiogram showed mild left ventricular hypertrophy. A CT scan of the brain showed three left thalamoganglionic infarcts and left parieto-occipital area infarct.
Patient was started on Monocef (2gms intravenously 12 hourly) and Azithral (250mg 12 hourly on first day and once daily from second day) and supportive therapy. A set of blood cultures were sent to microbiology. Injection metronidazole (500mg intravenously 8 hourly) was added to therapy, to cover for the anaerobic spectrum. Culture of blood, urine, CSF and a superficial swab from skin lesions for bacteria and fungus was sterile. Throat swab showed growth of C. albicans.
Despite the therapy, she continued to deteriorate. The case was reviewed and re - examined by a senior neurologist. At this point, multiple pustules with surrounding erythema all over the body were detected. On further questioning, the patient gave history of contact with stagnant water eight days prior to fever (rainwater due to floods). The pustules were aspirated and the pus was sent for microbiology work up. [Table - 1] shows the tests performed in Microbiology. Antibiotic sensitivity (as shown in [Table - 1] was different from the usual pattern seen for Pseudomonas aeruginosa. Based on conventional tests results of the isolate [Table - 2] and the antibiogram, the isolate was identified as a probable Pseudomonas species other than Pseudomonas aeruginosa.
After literature survey and discussion between the treating clinicians and the microbiologists, the patient was put on injection imipenem. The rest of the treatment was continued. After two days of imepenem, the patient became conscious, afebrile and the skin lesions began to subside. However, on the next day, the patient's condition worsened and she developed facial palsy on right side and ecchymotic patches all over the body and disseminated intravascular coagulopathy. Her renal parameters worsened. Due to persistent upper gastrointestinal bleed no anticoagulants were given. She went into respiratory distress due to aspiration and succumbed to death.
Confirmation of the bacterial isolate
Further identification of the isolate was done by the 'Neferm', an identification test kit for Non Fermenting Gram negative bacilli (Lachema, Israel) and the API system (BioMerieux, France). Both the panels identified the isolate as Burkholderia pseudomallei.
In addition, the isolate was sent to Christian Medical College and hospital (CMCH), Vellore, Tamilnadu, India, a reference centre for  B.pseudomallei   and non-fermenters. Biochemical tests and agglutination with specific antiserum to B.pseudomallei confirmed our identification.

 ~ Discussion Top

B.pseudomallei is a saprophyte found in soil and surface water[3] mainly in tropical and subtropical areas of South East Asia. Persons, who have regular contact with soil or ground water, most often contract infection with B.pseudomallei, especially during the wet season, probably through pre-existing skin lesions or penetrating wounds especially in immunocompromised patients.[4] It is now recognized as an emerging infection and an important cause of morbidity and mortality in several countries across the globe.
The clinical features of Melioidosis have a wide spectrum ranging from a short febrile illness or localized abscess to fatal septicaemia.[1] The first case of Melioidosis from India was reported in a child from Dapoli taluka in Maharashtra in 1990.[5] Six cases were diagnosed at CMCH, between September1993 and September 1995,[6] that were reported and referred from several states [Table - 3]. Later another three cases were reported from Orissa, West Bengal and Assam all of which were confirmed at CMCH. In all these cases, the clinical presentation was highly variable and most of them had diabetes mellitus as the common predisposing disease as was also seen in our patient. One interesting feature in the first case reported from rural Maharashtra was a specific history of contact with stagnant water. In a study over 12-year period, 17 cases of Meliodosis have been reported from Taiwan which is now considered as endemic for the infection.[8]
Later 3 more cases were reported from Orissa, West Bengal and Assam - confirmed at CMCH, Vellore.
The causative organism, B. pseudomallei may be mistaken for Pseudomonas species, since they share several common phenotypic characteristics. A clear understanding of the culture characteristics and biochemical reactions is essential for recognizing this pathogen in the diagnostic microbiology laboratory.[1]
The infection is underdiagnosed in India, probably due to a low index of suspicion among the clinicians and the clinical microbiologists.[7] The causative organism is not difficult to grow and modern antibiotics have improved disease prognosis.[3] Further epidemiological studies are needed to determine the prevalence of Melioidosis so that improved therapeutic and preventive measures can be developed and applied.[3]

 ~ Acknowledgements Top

We thank Professor Mary Jesudason, CMCH, Vellore, Tamilnadu, India, for confirming the identification of the isolate. We also thank Dr Savitri Sharma, LV Prasad Eye Institute, Hyderabad, Andhra Pradesh, India, for her help in the initial identification of the isolate by the API system. 

 ~ References Top

1.Jesudason MV, Kumari RS, John TJ. Burkholderia pseudomallei-An emerging pathogen in India. Indian J Med Microbiol 1997;15(1):1-2.  Back to cited text no. 1    
2.Handa R, Bhatia S, Wali JP. Melioidosis: a rare but not forgotten cause of fever of unknown origin. Br J Clin Pract1996;50(2):116-17.  Back to cited text no. 2    
3.Dance DA. Melioidosis: the tip of the iceberg? Clin Microbiol Rev 1991;4(1):52-60.  Back to cited text no. 3    
4.Rode JW, Webling DD. Melioidosis in the Northern Territory of Australia. Med J Aust 1981;1(4):181-84.  Back to cited text no. 4    
5.Raghavan KR, Shenoi RP, Zaer F, Aiyar R, Ramamoorthy R, Mehta MN. Meliodosis in India. Indian Pediatr 1991;28:184-188.  Back to cited text no. 5    
6.John TJ, Jesudason MV, Lalitha MK, Ganesh A, Mohandas V, Cherian T, Mathai D, Mathew JC. Melioidosis in India: The tip of the iceberg? Indian J Med Res 1996;103: 62-65.  Back to cited text no. 6    
7.Mathew S, Perakath B, Mathew G, Sitaram V, Nair A, Lalitha MK, John TJ. Surgical presentation of melioidosis in India. Natl Med J India 1999;12(2):59-61.   Back to cited text no. 7    
8.Hsueh PR, Teng LJ, Lee LN, Yu CJ, Yang PC, Ho SW, Luh KT. Melioidosis: An emerging infection in Taiwan? Emerging Infectious Diseases 2001;7(3):428-433.   Back to cited text no. 8    
9.Baron EJ, Peterson LR, Finegold SM. Non-Fermentative Gram negative bacilli. In: Bailey & Scott's Diagnostic Microbiology, 9th ed. ( C.V. Mosby Co., St Louis) 1994:386-405.  Back to cited text no. 9    
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