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CASE REPORT
Year : 2004  |  Volume : 22  |  Issue : 4  |  Page : 266-268
 

Burkholderia pseudomallei septicaemia - A case report


Department of Microbiology, Fr. Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka, India

Date of Submission26-Feb-2004
Date of Acceptance05-May-2004

Correspondence Address:
Department of Microbiology, Fr. Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka, India

 ~ Abstract 

Burkholderia pseudomallei, a natural saprophyte widely distributed in soil, stagnant waters of endemic areas, is said to infect humans through breaks in the skin or through inhalation causing protean clinical manifestations including fatal septicaemia. A case of septicaemia in a elderly female diabetic due to B. pseudomallei following a history of fall is being reported with complete details.

How to cite this article:
Dias M, Antony B, Aithala S, Hanumanthappa B, Pinto H, Rekha B. Burkholderia pseudomallei septicaemia - A case report. Indian J Med Microbiol 2004;22:266-8


How to cite this URL:
Dias M, Antony B, Aithala S, Hanumanthappa B, Pinto H, Rekha B. Burkholderia pseudomallei septicaemia - A case report. Indian J Med Microbiol [serial online] 2004 [cited 2019 Sep 17];22:266-8. Available from: http://www.ijmm.org/text.asp?2004/22/4/266/12823


Burkholderia pseudomallei earlier known as Pseudomonas pseudomallei or Whitmore's bacillus, has emerged as a significant pathogen in the past few years.[1] Occasional reports of melioidosis from various parts of India since 1990 implies its clinical severity.[2] A soil saprophyte by nature, B. pseudomallei is restricted to tropical and subtropical areas of Australia and south east Asia.[3] Melioidosis has protean manifestations which range from a short febrile illness or localized acute or chronic suppurative infection to fatal septicaemia.[1] A case of septicaemia due to B.pseudomallei in an elderly diabetic female patient is reported here. As the third reported case from the south coastal districts of Karnataka, it points out the increased prevalence of this organism in this area.

 ~ Case Report Top

A 62 year old lady, residing in a village near Mangalore, presented with high grade fever, vomiting, severe pain in the neck with restricted neck movements following a fall few days back, was admitted to Fr Muller Medical College Hospital, Mangalore, in the month of July 2003. She was a known diabetic and hypertensive. At the time of admission she was conscious. Local examination of the nape of the neck revealed neck cellulitis with severe tenderness, restricted neck movements and local rise of temperature.
Incision and drainage of neck cellulitis was done and serosanguinous fluid obtained was sent for culture and sensitivity. Laboratory investigations showed elevated total counts (20,000 cells/cumm), ESR - 78 mm/hr and elevated fasting and post prandial sugars (143 mg/dL and 199 mg/dL) respectively. There was no trace of urine ketone bodies. Ultrasonography of the abdomen showed enlarged liver with features of toxic hepatitis. Chest X-ray, ECHO and computerized tomography of neck and skull were normal. Skin biopsy from the involved area of the neck showed acute inflammatory infiltrates with ulceration and necrosis.
Sputum tested for the presence of acid fast bacilli was found to be negative. Blood sample was examined for unknown febrile aetiology including widal test, tests for malarial parasite, HIV and autoimmune markers all of which were negative. No growth was obtained from blood, CSF and the serosanguinous fluid from the cellulitis which was sent at the time of admission. Patient was started on inj. ciprofloxacin (100 mL bd), inj. omnatax (1gm bd), and inj. metronidazole 100 mg 8 hourly. About a week after admission, she developed multiple pustules with surrounding erythema all over the body. These pustules were aspirated and 'thick pus' like material was sent to microbiology laboratory for culture.
The Gram stain of the pus showed gram negative bacilli which grew as minute non-lactose fermenting colonies on MacConkey's agar and pin point non haemolytic colonies on blood agar. The organism was motile, oxidase and catalase positive, a non fermenter and utilized citrate and did not produce indole and H2S or hydrolysed urease. It was presumptively identified as Pseudomonas spp. other than Pseudomonas aeruginosa.
After 2-3 days the patient developed sudden onset of breathlessness with cyanosis and falling O2 saturation. Chest X-ray revealed ground glass appearance on the entire right side which was diagnosed as acute respiratory distress syndrome. Steroids, bronchodilators and ceftazidime were added to the treatment regimen. Inspite of the intensive treatment, the condition of the patient continued to deteriorate. She became restless and stuporous and was shifted to intensive care unit. She developed respiratory distress and eventually succumbed to the infection after 4 days.
Meanwhile, the pleomorphic organism isolated from the aspiration, showed bipolar staining and aroused the suspicion of B. pseudomallei. On further incubation, the colonies on MacConkey's agar became pink, dry and wrinkled which is a typical feature of this organism. Colonies on blood agar exhibited hazy zone of lysis. Subsequently, the organism was characterized according to the standard procedures meant for Pseudomonas speciation.[4] It utilized glucose, lactose and starch oxidatively, decarboxylated arginine, liquified gelatin, reduced nitrate and grew well at 42C suggesting it to be B. pseudomallei.
The isolate was sent to Christian Medical College and Hospital, Vellore, Tamilnadu, the reference centre for B. pseudomallei, for confirming the identity of the same. Biochemical characterisation and agglutination with B. pseudomallei antiserum (positive reaction of 4+) further confirmed our identification.

 ~ Discussion Top

Burkholderia pseudomallei is a natural saprophyte widely distributed in soil, stagnant water of endemic areas. Melioidosis which is a glanders like infectious disease of humans caused by B. pseudomallei presents with a varied clinical spectrum with high morbidity and mortality. Human infection occurs through direct inoculation, through damaged skin or mucous membranes or through inhalation.[3] Acute localized suppurative infection due to contamination of skin abrasions by B. pseudomallei rapidly progresses to a septicaemic form.[1] In this patient, the neck cellulitis developed following a fall, and might have initiated infection, which progressed to septicaemia within a short duration. Majority of the cases have been documented from various parts of the country experiencing heavy rainfall.[5] In this case also infection occurred in the month of July during which time this region experiences a heavy rainfall. A recent report from Hyderabad also isolated B.pseudomallei from septicaemia following contact with stagnant water.[5]
Melioidosis which was once considered exotic in our country has been reported from Tripura in the north east to Kerala in the south. Our limited review of literature suggests that this is the third case to be reported from south coastal districts of Karnataka, the other two being reported from Manipal - one from a case of hepatic abscess in a 45 year old diabetic woman[6] and the other one in a 12 year old girl with an abscess in the parotid region,[7] suggesting that this bacteria is prevalent in this region of Karnataka. Though there are contrasting views regarding the predilection of this organism for debilitating patients,[1] most of the cases reported from India, including our case, had diabetes mellitus as a predisposing factor.[5],[6] The organism has been found to infect all age groups.[1],[7] It is important to treat suspected cases with antibiotics before any manipulation of the patient, especially surgical procedure is done.[5],[8] This was demonstrated in our patient who progressed to fulminant septicaemia within a short time following incision and drainage of the cellulitis.
We were not successful in isolating B. pseudomallei from blood culture, though the patient developed septicaemia. No growth was obtained from the blood culture which was sent during the initial period of illness before the appearance of pustules, which indicates the localization of the bacteria in the neck cellulitis. During the detailed identification of the organism and its confirmation as B. pseudomallei, the condition of the patient deteriorated and she died.
B. pseudomallei, the emerging pathogen, is overlooked in many cases due to the low index of suspicion and awareness among microbiologists and clinicians. Therefore, due consideration should be given to this organism to know the true magnitude of melioidosis in our country. As B. pseudomallei is a non fastidious organism without any exacting growth requirements, all non fermenters should be subjected to speciation as a part of routine microbiological work up. 

 ~ References Top

1.Sanford JP. Pseudomonas species (including melioidosis and Glanders) chapter 197. In: Principles and Practice of Infectious diseases. 3rd ed. Mandel, Douglas, Bennet. Eds (Churchill Livingstone, London) 1990:1693-1694.  Back to cited text no. 1    
2.Raghavan KR, Shenoi RP, Zaer F, Aiyar R, Ramamoorthy R, Mehta MN. Meliodiosis in India. Indian Paediatrics 1991;28:184-188.   Back to cited text no. 2    
3.Forbes BA, Sahm DF, Weissfield AS. Pseudomonas, Burkholderia and similar organisms chapter 31 Bailey and Scott's Diagnostic Microbiology. 10th ed (Mosby Co. St. Louis) 1998:448-450.  Back to cited text no. 3    
4.Jesudasan MV, Shantha Kumari R, John TJ, Burkholderia pseudomallei - An emerging pathogen in India. Indian J Med Microbiol 1997;15:1-2.  Back to cited text no. 4    
5.Anuradha K, Meena AK, Lakshmi V. Isolation of Burkholderia pseudomallei from a case of Septicaemia - A case report - Indian J Med Microbiol 2003;21:129-132.  Back to cited text no. 5    
6.Sengupta S, Murthy R, Kumari GR, Rahana K, Vidhyasagar S, Bhat BKS, Shivananda PG. Burkholderia pseudomallei in a case of hepatic abscess. Indian J Med Microbiol 1998;16: 88-89.  Back to cited text no. 6    
7.Rao PS, Shivananda PG. Burkholderia pseudomallei - Abscess in an unusual site. Indian J Pathol Microbiol 1999;42:493-494.   Back to cited text no. 7    
8.Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn Jr. WC. Taxonomy, biochemical characteristics and clinical significance of nonfermenters. Color Altas and Text book of Diagnostic Microbiology, 5th edition (Lippincot - Raven Publishers) 1997:269-270.  Back to cited text no. 8    
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2004 - Indian Journal of Medical Microbiology
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