A case report of melioidosis complicated by infective sacroiliitis in Sri Lanka

Abstract

BackgroundMelioidosis is an infection caused by a facultative intracellular Gram-negative bacterium, Burkholderia pseudomallei. It can present as septicemia, localized infection with/without septicemia, asymptomatic infections, ulcers, pneumonia, visceral abscesses, neurological infection, musculoskeletal infections and can involve any organ.Case presentationA 56 year old Sri Lankan diabetic female presented with fever, chills and rigors for 2 weeks. She also had malaise and loss of appetite, but no other features. On examination, she was febrile (temperature was 101.4 0 F) and rest of the examination was unremarkable. Her blood culture was positive for Burkholderia pseudomallei and she was started on IV antibiotics, on day 3. During her 2nd week of hospital stay, she developed right sided low back pain with buttock pain, right hip joint pain and restricted hip joint movements suggestive of right sacroiliitis. CE CT and MRI scans confirmed the diagnosis of right iliopsoas abscesses and right sacroiliitis.Incision and drainage was performed and a pigtail catheter was left in place for continuous drainage of abscesses. Her intensive phase was initiated with IV ceftazidime 2 g every 6 h for 12 days, then changed over to IV meropenem 2 g every 8 h together with oral co-trimoxazole. 2 weeks later, oral co-trimoxazole was replaced by oral doxycycline for another 6 weeks (due to transient pancytopaenia). She made a complete and uneventful recovery with oral co-trimoxazole for another 6 months, in her eradication phase.We report this case to show the importance in early diagnosis of melioidosis, and to consider it in the differential diagnosis of multiple abscesses and to emphasize the importance in suspecting melioidosis as a causative agent in infective sacroiliitis.DiscussionMelioidosis can have 2 major presentations; acute infection (symptoms lasting less than 2 months) and chronic infection (symptoms lasting more than 2 months). Musculoskeletal melioidosis is a well-recognized manifestation of the disease, which can manifest as soft tissue abscesses, septic arthritis, spondylitis, sacroiliitis and osteomyelitis.Management of melioidosis consists of 2 phases. The intensive phase and the eradication phase. These are aimed at the importance of rapidly treating the septicemia, the need of eradication of the persistent disease and the prevention of recurrent infections or relapses. The intensive phase consists of minimum 10–14 days of IV antibiotics: IV ceftazidime or IV carbapenem (meropenem/ imipenem). Eradication phase should be followed by 3–6 months of oral co-trimoxazole alone or in combination with oral doxycycline/ oral amoxiciliin-clavulanic acid.

Disseminated Melioidosis Presenting with Community-Acquired Pneumonia: A Presentation Not to be Missed – A Case Report

“…Other medical conditions such as chronic kidney disease and excessive alcohol consumption have also been implicated [2], [8]. Exposure to contaminated water or soil in an occupation related to the agriculture industry and to a smaller extent in farming, fishing, and forestry activities has also been reported [2], [5], [7], [8]. Our patient had two predisposing factors; an underlying immunocompromised state and a contact with possibly contaminated soil and freshwater.…”

“…This opportunistic organism, B. pseudomallei, tends to cause infection in those with diabetes mellitus and is the most common factor observed in Malaysia [7]. Other medical conditions such as chronic kidney disease and excessive alcohol consumption have also been implicated [2], [8]. Exposure to contaminated water or soil in an occupation related to the agriculture industry and to a smaller extent in farming, fishing, and forestry activities has also been reported [2], [5], [7], [8].…”

Severe Sepsis with Multiorgan Failure due to Melioidosis: A Lesson to Learn

“…Severe infection is common in patients with diabetes, renal disease, liver disease, alcohol consumption, and thalassemia [ 5 ]. People who have exposure to wet soils or water such as farmers, manual labourers, workers of building construction sites, and surveyors or who are involved in gardening and fishing are at a high risk of getting Burkholderia pseudomallei infection [ 5 ]. This patient, although he was immunocompetent, had occupational exposure.…”

“…Direct inoculation of the organism on the wound via damaged skin from the wet soil and water in the paddy field might be the mode of transmission of the infection. High degree of suspicion of melioidosis is needed when the patient is from an endemic area with a potential exposure history [ 5 , 9 , 10 ].…”

“…Severe infection is common among people with comorbidities such as diabetes mellitus, renal disease, liver disease, alcohol consumption, and thalassemia. Occupational exposure to surface water and mud in the form of agriculture, farming, fishing, gardening, land surveying, building construction, and manual labouring are risk factors for melioidosis [ 4 , 5 ]. A study conducted in Sri Lanka reported melioidosis in Sri Lanka has wide geographical distribution and it is common in rice-growing rural areas [ 1 ].…”