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 ~  Abstract
 ~ Introduction
 ~ Material and Methods
 ~ Results
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BRIEF COMMUNICATION
Year : 2019  |  Volume : 37  |  Issue : 3  |  Page : 430-432
 

Melioidosis in Odisha: A clinico-microbiological and epidemiological description of culture-confirmed cases over a 2-year period


1 Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
4 Department of Pulmonary Medicine and Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
5 Department of ENT, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
6 Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission28-Oct-2019
Date of Decision02-Nov-2019
Date of Acceptance14-Nov-2019
Date of Web Publication05-Dec-2019

Correspondence Address:
Dr. Baijayantimala Mishra
Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_19_367

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 ~ Abstract 


Melioidosis is an emerging infectious disease in India mostly reported from South-western coastal Karnataka and North-eastern Tamil Nadu. We speculate the existence of another major hidden focus in Odisha, one of the eastern coastal states. The clinico-epidemiological features of 47 culture-confirmed melioidosis at a tertiary care teaching hospital over a period of 2 years are reported. Septicaemia was the most common clinical presentation. Diabetes mellitus (DM) was present in 72.3% of our cases. The geo-climatic conditions of Odisha and other coastal states of India and the rise in the incidence of DM demand a nationwide surveillance of melioidosis and creation of melioidosis registry.


Keywords: Burkholderia pseudomallei, Odisha, melioidosis


How to cite this article:
Behera B, Mohanty S, Mahapatra A, Hallur VK, Mishra B, Dey A, Kumar R, Mishra TK, Sasmal PK, Sinha M, Mohapatra PR, Panigrahi MK, Preetam C, Das RR. Melioidosis in Odisha: A clinico-microbiological and epidemiological description of culture-confirmed cases over a 2-year period. Indian J Med Microbiol 2019;37:430-2

How to cite this URL:
Behera B, Mohanty S, Mahapatra A, Hallur VK, Mishra B, Dey A, Kumar R, Mishra TK, Sasmal PK, Sinha M, Mohapatra PR, Panigrahi MK, Preetam C, Das RR. Melioidosis in Odisha: A clinico-microbiological and epidemiological description of culture-confirmed cases over a 2-year period. Indian J Med Microbiol [serial online] 2019 [cited 2020 Apr 9];37:430-2. Available from: http://www.ijmm.org/text.asp?2019/37/3/430/272349





 ~ Introduction Top


Melioidosis is an emerging infectious disease in India which is under-diagnosed due to its protean clinical manifestations and difficulty in laboratory diagnosis.[1] In India, most of the published case series are from South-western coastal Karnataka and North-eastern Tamil Nadu, and case reports are published from the entire country barring few Northern States.[1],[2] Odisha, one of the 29 states of India, is located on the eastern coast and has 485 km of coastline along the Bay of Bengal. The coastal region constitutes 23% of the geographical area of Odisha and receives an average annual rainfall of approximately 1449 mm. Following the detection of our first case, a case of fatal splenic abscess in 2015 and series of interactions with clinicians, we are regularly encountering culture-confirmed cases of melioidosis.[3],[4],[5] A detailed clinico-epidemiological description of 47 culture-confirmed cases over a 2-year period is presented here.


 ~ Material and Methods Top


Study setting

Forty-seven patients with culture-confirmed melioidosis treated at a newly commissioned tertiary care teaching hospital in Odisha from 2015 to 2017 were included in the present analysis. Patient demographics, clinical characteristics, treatment and final outcome details were retrieved from the case sheets. The cases are described under the following headings:

  1. Bacteraemic without identifiable focus
  2. Bacteraemic with identifiable focus
  3. Non-bacteraemic cases (focal)


    1. Internal organ abscess
    2. Superficial skin and structure infections
    3. Lymphadenitis
    4. Pneumonia
    5. Bone and joint infections
    6. Neurological.


Clinical specimens were processed as per the standard microbiological culture techniques. Phenotypic identification was performed by the combination of the following tests, i.e., characteristic metallic sheen and wrinkled appearance of colonies, oxidase positive, motile, Gram-negative bacilli with bipolar staining with a 'safety-pin' appearance; resistance to polymyxins antibiotics (colistin 10 μg and polymyxin B 300 U disks) along with arginine dihydrolase positive reaction. The final identification of isolates was also confirmed by Burkholderia pseudomallei capsular polysaccharide antigen detection (InBiOS AMD rapid diagnostic test, Seattle, USA) and (Type III secretion system) TTS-1 polymerase chain reaction. Antimicrobial susceptibility was interpreted as per the standard procedure laid down by the Mahidol University.[6] The following antibiotics (ceftazidime, imipenem, meropenem, trimethoprim-sulphamethoxazole, amoxicillin-clavulanic acid, doxycycline and chloramphenicol) were tested by disc diffusion test as well as by the E test.


 ~ Results Top


Of the 47 cases, four cases were native of West Bengal and two cases were from Uttar Pradesh. The district-wise distribution of remaining 41 culture-confirmed melioidosis is shown in [Figure 1]. Maximum cases (17/41; 41.4%) were from Khordha District. Of 47 culture-confirmed melioidosis cases, 26 isolates were from bacteraemic cases. Of 26 bacteraemic isolates, 19 were isolated only from blood and 7 were isolated from both blood and pus/aspirate/tissue. There was overall male gender predisposition (74.4%, 35/47) as well as in bacteraemic cases (88.4%, 23/26). The mean age of bacteraemic cases was 52.04 years (24–84 years), and the mean age of non-bacteraemic cases was 38.2 (1–70) years. The bacteraemic cases peaked between July and November, with no cases reported being reported from December to March. Although the non-bacteraemic cases had a similar peak between July and November, individual cases were reported almost every month. The mean duration of symptoms both the bacteraemic cases and non-bacteraemic cases before seeking health care was 35.2 days (7–90) and 33.2 (21–90) days, respectively. Diabetes mellitus (DM) was present in (23/26, 88.4%) of bacteraemic cases and (11/21, 52.3%) of non-bacteraemic cases. The demographic findings, presenting symptoms and outcome are further elaborated in [Table 1].
Figure 1: District-wise distribution of melioidosis

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Table 1: Demographic findings, presenting symptoms and outcome of culture-confirmed cases of melioidosis

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Intravenous ceftazidime was administered at the recommended dosage (50 mg/kg body weight, every 6–8 hourly in all cases except in 5 bacteraemic cases who were in sepsis and were administered meropenem (25 mg/kg body weight, every 8 hourly, up to 1 g). Seven bacteraemic cases succumbed to septic shock. Cotrimoxazole was the 1st choice for eradication phase. All the isolates retained susceptibility to tested carbapenems (meropenem and imipenem). Ceftazidime resistance was noted in only two isolates (two bacteraemic). Trimethoprim-sulphamethoxazole resistance was noted in three isolates (two bacteraemic and one non-bacteraemic), who were administered Amox/clav in the eradication phase.


 ~ Discussion Top


Our findings are comparable with the recently published findings from the state of Karnataka and Tamil Nadu, the hitherto melioidosis hot spots of India.[1],[7] The findings of 47 cases of culture-confirmed melioidosis cases over a 2-year period from a single centre resonate with the fact that there is a major hidden focus of melioidosis in Odisha. The findings of large number of cases can be solely attributed to heightened awareness among clinicians and microbiologists. This potentially fatal disease was lurking in the environment and was probably labelled as fever of unknown origin most of the times.

The mean age range and the male gender predisposition are consistent with previous studies.[1],[7],[8] Similarly to other series from India, the cases peaked during monsoon and post-monsoon.[1],[7] One noteworthy observation though was the relative absence of bacteraemic cases during summer and winter months, whereas the non-bacteraemic superficial abscesses were reported all throughout the year.

DM was present in 72.3% of our cases, which is in concordance with other recently published series from India.[1],[7] Bacteraemic cases (52.04%) were relatively more than non-bacteraemic cases (38.2%). This finding matches with that of Koshy et al. who analysed 118 culture-confirmed melioidosis during January 2008–December 2014, and bacteraemia was present in 55.2% of cases.[7] The cervical lymphadenitis cases are worth special mention as these masquerade as tubercular lymphadenitis.

The use of enrichment culture, antigen detection and nucleic acid tests is also suggested for the optimisation of laboratory diagnosis by experts.[6],[9] In an effort to detect additional cases, some of these measures are being currently introduced to our laboratory practice in a phase-wise manner and will be definitely detect more cases in the future.

The environmental and demographic factors of Odisha in terms of rainfall and temperature, extent of paddy cultivation, percentage of population with diabetes and construction boom are strongly favourable for melioidosis. To conclude, Odisha is an important focus of melioidosis and our findings will add to the Indian literature on melioidosis. There is an urgent need for the creation of awareness among clinicians, microbiologists, capacity building of the microbiology laboratories and creation of a national melioidosis registry.[9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
Mukhopadhyay C, Shaw T, Varghese GM, Dance DAB. Melioidosis in South Asia (India, Nepal, Pakistan, Bhutan and Afghanistan). Trop Med Infect Dis 2018;3. pii: E51.  Back to cited text no. 1
    
2.
Tipre M, Kingsley PV, Smith T, Leader M, Sathiakumar N. Melioidosis in India and Bangladesh: A review of case reports. Asian Pac J Trop Med 2018; 11:320-9.  Back to cited text no. 2
  [Full text]  
3.
Behera B, Praharaj AK, Sasmal PK, Dhal S, Choudhury S, Turuk J. A case of fatal septicaemic melioidosis from Odisha. Tropical Gastroenterology 2017; 38:134-7.  Back to cited text no. 3
    
4.
Behera B, Mohanty S, Mishra BM, Praharaj AK. Melioidosis: An underdiagnosed entity in Odisha. A series of four cases over a two months period. Int J Infect Dis 2016;45:166.  Back to cited text no. 4
    
5.
Mohanty S, Pradhan G, Panigrahi MK, Mohapatra PR, Mishra B. A case of systemic melioidosis: Unravelling the etiology of chronic unexplained fever with multiple presentations. Pneumonol Alergol Pol 2016;84:121-5.  Back to cited text no. 5
    
6.
Standard Operating Procedure (SOP) for Isolation of Burkholderia pseudomallei from Clinical Samples. Mahidol Oxford Tropical Medicine Research Unit; 2015.  Back to cited text no. 6
    
7.
Koshy M, Jagannati M, Ralph R, Victor P, David T, Sathyendra S, et al. Clinical manifestations, antimicrobial drug susceptibility patterns, and outcomes in melioidosis cases, India. Emerg Infect Dis 2019;25:316-20.  Back to cited text no. 7
    
8.
Tellapragada C, Shaw T, D'Souza A, Eshwara VK, Mukhopadhyay C. Improved detection of Burkholderia pseudomallei from non-blood clinical specimens using enrichment culture and PCR: Narrowing diagnostic gap in resource-constrained settings. Trop Med Int Health 2017;22:866-70.  Back to cited text no. 8
    
9.
Mohapatra PR, Behera B, Mohanty S, Bhuniya S, Mishra B. Melioidosis. Lancet Infect Dis 2019;19:1056-7.  Back to cited text no. 9
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]



 

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