This document presents a case study of a 36-year-old man admitted to the hospital with fever, abdominal pain, and lack of appetite. Initial tests showed jaundice and liver abnormalities. Further evaluation found a liver abscess. The patient was treated but had a similar prior illness in Malaysia. Tests identified the cause as melioidosis, a tropical disease caused by the bacterium Burkholderia pseudomallei. The patient received long-term antibiotic treatment and follow-up showed the infection had resolved. The presentation discusses the epidemiology, pathogenesis, diagnosis and treatment of melioidosis.

1. Welcome
to
Weekly Scientific Seminar

2. Clinical Presentation
Presented by
Dr. Ahmed Shahed
RMO (Green Unit)
Medicine Department
HFRCMCH

3. (1) High grade fever for 15 days.
(2) Right upper abdominal pain for same duration.
(3) Lack of appetite , nausea, vomiting for same
duration.
The temperature was 104°F, Blood pressure 120/70 mm
Hg, and heart rate 100 beats per minute, Jaundice (++),
Hyperaesthesia present over right hypochondriac
region, mild dull aching upper abdominal pain and
tenderness over the back. The other physical
examinations were normal.
In the winter of 2016, a 36-year-old man admitted in our hospital
through emergency department with the complaints of

4. (1) Hb level : 8.2 g /dl.
(2) WBC count : 12,900 /cumm, with 75%
neutrophils, ESR : 55 mm/1st hr.
(3) Platelet count : 336,000/cu mm
(4) PCV 25.7%, MCV 63.5 fl, MCH 20.2pg,
MCHC 31.9g/dl
(5) RBS 14.6 mmol/l.

5. The presumed diagnosis was Liver
abscess with DM.
The patient was treated with Intravenous fluids,
Injectable Ondansetron, Ceftazidime,
Metronidazole, Omeprazole, Tiemonium
Methylsulphate ,Short and long acting Insulin.

6. • Acute viral hepatitis
• Malaria.
• Pancreatitis.

7. In the next morning, we got some additional laboratory data
obtained last evening
(1) Serum electrolytes Na+ 131, K+ 4.9, Cl- 93.2 mmol/l
(2) Creatinine 1.1 g/dl ( 0.6 to 1.3 )g/dl
(3) ALT (SGPT) 24 U/l (normal range, up to 40 IU/l),
(4) AST 19 U/l (normal range, 8 – 41 IU/l)
(5) Bilirubin 2.7 mg /dl (0.2 – 1.1 mg/dl)
(6) Alkaline Phosphatase 222.47 IU/lL( 30-120 IU/L)
(7) Serum Amylase 59 U/L ( 0- 130U/L) , Lipase 110 U/L
(0-160U/L)

8. • Hospital admission ?
• What would be the
possibilities?
1. Hepatitis- Alcohol/Viral/
Idiosyncratic drug
reaction.
2. Malaria

9. The next second morning we had review of the case.
Fever ( 102°F) and abdominal pain was slightly
subsided. There was no vomiting in last 24 hrs.
He reported no alcohol use, drug abuse, blood
transfusion, physical contact or travelling to
malaria endemic zone .
The blood pressure was 120/85 mm Hg.

10. (1) Hb level 8.5 g/dl, WBC count 12,000/cumm with 70%
neutrophils and, platelet count 3,30,000/cumm of blood.
(2) HBsAg (0.050) Negative.
(3) Anti HCV (0.061) Negative.
(4) Total bilirubin level 2.0 mg/dl
(5) Prothombin time of patient 20.4 sec and control 13.0. INR
1.56
(6)FBS 8.6 mmol/l, 2HABF 10 mmol/l
(7) ICT Malaria – Negative. Blood for MP – Not detected.
(8) CXR- Normal

11. USG of whole abdomen shows one irregular
hypoechoic lesion ( 6.8x 3.6 cm) in right lobe.
No ascites or pleural effusion is seen.
Comment: SOL in right lobe of liver.

12. Liver Abscess
 Metastatic Lesion in
liver.

13. During further evaluation, patient reveals some past history
Which he didn’t mentioned earlier…..
He had a similar kind of illness while he was working
abroad (Malaysia) 6 months back. For that he got
admitted in the hospital there and they did several
investigations and gave him injectable medications.
But he failed to show any related documents except
one paper.
(1) He was febrile.( 102°F)
(2) His blood pressure was 130/80mm Hg.
(3) The remainder of his physical examination was
normal.

14. (1) AFP 1.90 ng/ml ( < 8.5 )
(2) CEA 9.33 ng/ml ( Up to non smoker 5, smoker 10 )
(3) CA- 19-9 = 29.21 U/ml ( <40.0 )
(4) CRP 20, (< 6)
(5) Video Colonoscopy - Normal rectum and colon at
colonoscopy
(6) Blood for C/S – No growth.
(8) CT Scan of Upper Abdomen
a) Mild Hepatomegaly, b) Multiple indistinct hypodense SOL.

15. CT Scan of Abdomen

16. Video Colonoscopy Report

17. In recalling the precise moment and investigations
from Malaysia
(1) USG of Whole Abdomen – Partially liquefied
liver abscess at segment VII and VIII, measuring
8.9 (AP) x 4.9 cm (W). (26/6/2016)
(2) USG of whole Abdomen- Partially liquefied
liver abscess involving segment VII and VIII 10.9x
5.7 cm. A new irregular hypoechoic lesion in the
spleen likely splenic abscess.( 08/07/2016)
Melioidosis serology IgM : Positive (1: 320)

18. • What should be the next Plan?
How should we approach the case?

19. Next plan and approaches ……….
Consultation given to the Surgery department
Surgery Department examined the patient, Gave
advice to transfuse one unit whole blood after proper
grouping, crossmatching and adviced some
investigations…….
USG of whole abdomen (Review) – Liver normal in
size, Two mixed hypoechoic cystic masses, measuring
about vol. 49cc , seen in the anterior superior aspect
of right lobe of liver.
Spleen – Few tiny cysts noted.
Impression – (1) Liver abscess. (2) Tiny splenic cysts.

20.  USG guided Catheter drainage done under
L/A…….

21. 3 days to go………

22. Melioidosis

23. History
• 1912, Alfred Whitmore
• Burma
• Organism isolated
in humans
− Glanders-like disease
− No equine exposure
− Colony growth differed
from glanders
− “Whitmore” disease Alfred Whitmore 1876-1941
Center for Food Security and Public Health
Io
• The name melioidosis is derived from Greek word ‘melis’
meaning a distemper of asses with suffixes ‘oid’meaning similar
to and ‘osis’ meaning a condition that is, a condition similar to
glanders.

24. History
• 1913, Malaysia
• Stanton and Fletcher
• “Distemper-like”
outbreak in animals
• Pioneered serological
tests
Ambrose
Thomas
Stanton
Center for Food Security and Public Health Io
William
Fletcher

25. History
• 1948-1954, Indo-China
− Over 100 French soldiers
• 1973, Vietnam
− Over 300 American soldiers
− “Vietnamese time bomb”
 Infections reoccurred after latent period
− Military dogs in Vietnam also affected
 Fever, myalgia, dermal abscesses
Center for Food Security and Public Health
Io

26. History
Center for Food Security and Public Health
Io
• 1970’s, France
− Numerous horses and zoo
animals affected
− Melioidosis in temperate climates
• 1989
− Effective antibiotic treatment
• Thailand had reported the highest number of cases, with an estimated 2000
to 3000 cases of melioidosis each year.

27. Epidemiology
• Melioidosis is predominately a disease of tropical
climates.
• It is endemic in Southeast Asia, northern Australia and
Brazil.
• Northeast Thailand has the highest incidence of
melioidosis.
• Septicemic meliodosis has high mortality, 87% in
Thailand, 75% in East Malaysia, 39% in Singapore and
19% inAustralia.
• Localised melioidosis has lower mortality.
(Mustafa, Murtaza, et al. "Clinical manifestations, diagnosis, and treatment of
Melioidosis." IOSR Journal of Pharmacy 5(2015): 13-19).

28. Bangladsh (20th July 2013)

29. In 1964, melioidosis was reported in a
foreign sailor who was travelling through
Bangladesh [7]. However, the first case of
melioidosis in Bangladesh was diagnosed
in a native Bangladeshi infant in
1988 [8]. Later on several cases of
melioidosis were reported up to 2014 [9].
Melioidosis presenting as septic arthritis
in Bengali men in East London
Article · October 1999 with 3
ReadsDOI:10.1093/rheumatology/38.10.
1029a
Burkholderia
pseudomallei: Its
Detection in Soil and
Seroprevalence in
Bangladesh
Article · January 2016
with 81 ReadsDOI:
10.1371/journal.pntd.000
4301
Disseminated
Meliodosis presenting
as septic shock: an
endemic disease of
Bangladesh
Article · February 2015
with 9 Reads

30. Melioidosis in Bangladesh
• 22 cases were identified, among them 19 were
published in different journals and 3 local cases
are yet to be published
Retrospective analysis of
meliodosis (1988-2015)
• 21 were diabetic and 18 were male. 16 cases
were classified as endemic while 6 cases were
reported as returning travelers from Bangladesh.
Results
• Lung involvement (8, 36.3%) and organ abscess (6,
27.2%).
Common Organ
involvement
• 14 cases responded to
ceftazidime/imipenem/meropenum
combination of doxycycline and trimethoprim-
sulfamethoxazole or amoxicillin-clavulanic acid.
In 3 cases treatment was not mentioned and 5
patients died despite of treatment.
Treatment Outcome
Uddin K.N., Afroze S.R., Rahim M.A., Barai L., Haq J.A.
BIRDEM General Hospital and Ibrahim Medical
College, Dhaka, Bangladesh

32. After 3 days……

33. • Successfully abscess drained and pus sent for culture at
BIRDEM Hospital
BIRDEM – Growth of Burkholderia pseudomallei.
Aztreonam S
Ceftazidime S
Ciprofloxacin S
Co-Ttimoxazole S
Imipenem S
Tazobactum + Pipercillin S
Tetracycline S

34. Culture Report

35. Final Diagnosis
• Melioidosis
• Rx
• Inj. Ceftazidime (2gm) i/v 8 hrly.
For 21 days, followed by Cap. Doxycycline
200 mg with Tab. Co-trimoxazole (S –
1600mg plus T- 320mg) for 12 weeks.

36. • Follow up of the patient after
complete the treatment…….
CBC
• Hb 9.6gm/dl,
WBC- 6.7 K/ʯl,
Neutrophil –
29.0%.
Bilirubin,
SGPT, CRP
• Bilirubin 0.61
mg/dl
• SGPT 32 U/l
• CRP < 6
USG of Whole
abdomen
• Normal
findings.

37. Take Home Message

39. Q and A

40. Mode of Transmission
1. Inhalation
2. Ingestion
3. Inoculation
4. breast milk
5. perinatal
6.human to human uncommon

41. Clinical manifestations
A shows cutaneous melioidosis in a healthy host.
B shows lung abscesses on the chest radiograph of a patient with acute melioidosis
pneumonia.
C shows the corresponding computed tomographic (CT) scan.
D shows the skin manifestations in a fatal case of disseminated melioidosis.
E shows splenic abscesses on an abdominal CT scan.
F shows aspirated pus in a patient with prostatic and periprostatic abscesses, and
G shows the abscesses on a CT scan from the patient.

42. Pathogenesis

43. Clinical manifestation
• Pulmonary infection
• Skin ulceration
• Lymphadenopathy
• Manifestations are exacerbated long after the exposure;
hence called as Vietnam time bomb disease.

44. Laboratory diagnosis
• Sample collection
1. Sputum
2. BAL
3. Blood or bone marrow
4. Urine and a
5. Throat swab
6. Pus and
7. Wound swab
8. Skin lesions
9. Rectal swab

45. Gram stain
• Gram stain:
• B. pseudomallei is a
Gram-negative bacillus.
• Measures about 2–5 μm in
length and 0.4–0.8 μm in
diameter.
• It frequently does not
show bipolar-staining on
Gram stain, but it is often
pleomorphic and usually
stains slightly unevenly.

46. Culture
• B. pseudomallei is not fastidious and grows on a
large variety of culture media (blood
agar, Chocolate agar, MacConkey agar, etc.).
• Ashdown's medium may be used for selective
isolation.
• Cultures typically become positive in 24 to 48 hours

47. Colony morphology:
• Smooth, creamy, white colonies on BA at 24 hrs
• Some may be mucoid or become dry and wrinkled
at 48 - 72 hrs
• Pink colonies on MA agar at 24 - 48 hrs or colorless
colonies at 48 hrs

48. Selective medium (Ashdown medium)
• Contains crystal violet and gentamicin as selective
agents.
• It is also enriched with 4% glycerol, which is
required by some strains of B. pseudomallei to
grow.
• It usually produces flat wrinkled purple colonies.
• Colonies will also exhibit an earthy odor.
• The colony appears irregular-edge, rough and pale
purple.

49. Biochemical test
• Catalase = Positive
• Oxidase = Positive
• Indole = Negative
• Motility = Positive
• Triple Sugar Iron (TSI) = K/NC
• Colistin/Polymyxin B = Resistant (no zone)

50. Biochemical Test

51. API 20NE biochemical Kit

52. Serology
• Strains of B.
pseudomallei are
identified serologically
by agglutination tests,
rapid slide or tube
agglutination
• Recently ELISA based
on monoclonal antitoxin
is avialble for rapid
diagnosis in endemic
areas of melioidosis.

53. Latex agglutination test
• Initial screening of suspected colonies from any agar medium
is undertaken by latex agglutination using latex particles
coated with antibodies specific for the 200-kDa
exopolysaccharide of B. pseudomallei.
Method:
• Pipette 10 μl of control and test latex onto a glass slide
• Note: Controls do not have to be tested with every sample but
should be run in tandem on each testing day.
• Using a toothpick, touch the suspected colony and emulsify
the colony in the test latex.
• Rotate the samples to mix to allow the reaction to occur.

54. Interpretation:
• Agglutination (positive) may be rapid or may take
up to 20 secs.
• Observe for at least 2 mins before declaring the
status of the sample as positive or negative.

55. • Indirect hemaggultination test (IHA).
• Various enzyme-linked immunosorbent assays
(ELISA),and other serological assays are also
available.
• PCR (polymerase chain reaction) which has also
been evaluated to detect B. pseudomallei genome in
pus, sputum, and other specimens.

56. Treatment

57. Treatment
• B. pseudomallei is intrinsically resistant to many
antibiotics, including aminoglycosides and early
betalactams (penicillin, ampicillin, first and second
generation cephalosporins, gentamicin, tobramycin,
and streotomycin).

58. Vaccine
• No vaccine are available