Transverse myelitis secondary to Melioidosis; A case report

Abstract

BackgroundMelioidosis has become an emerging infection in Sri Lanka; a country which is considered non endemic for it. Paraplegia due to Burkholderia pseudomallei is a very rare entity encountered even in countries where the disease is endemic. There are no reported cases of transverse myelitis due to melioidosis in Sri Lankan population thus we report the first case.Case presentationA 21 year old farmer presented with sudden onset bi lateral lower limb weakness, numbness and urine retention. Examination revealed flaccid areflexic lower limbs with a sensory loss of all modalities and a sensory level at T10 together with sphincter involvement. MRI of the thoracolumbar spine showed extensive myelitis of the thoracic spine complicating left psoas abscess without definite extension to the spinal cord or cord compression. Burkholderia pseudomallei was isolated from the psoas abscess pus cultures and the diagnosis of melioidosis was confirmed with high titers of Burkholderia pseudomallei antibodies and positive PCR. He was treated with high doses of IV ceftazidime and oral cotrimoxazole for one month with a plan to continue cotrimoxazole and doxycycline till one year. Patient’s general condition improved but the residual neurological problems persisted.ConclusionThe exact pathogenesis of spinal cord melioidosis is not quite certain except in the cases where there is direct microbial invasion, which does not appear to be the case in our patient. We postulate our patient’s presentation could be due to ischemia of the spinal cord following septic embolisation or thrombosis of spinal artery due to the abscess nearby. A neurotrophic exotoxin causing myelitis or post infectious immunological demyelination is yet another possibility. This emphasizes the necessity of further studies to elucidate the exact pathogenesis in this type of presentations.Health care professionals in Sri Lanka, where this is an emerging infection, need to improve their knowledge regarding this disease and should have high degree of suspicion to make a correct and a timely diagnosis to reduce the morbidity and mortality due to Burkholderia pseudomallei infection. It is highly likely that this infection is under diagnosed in developing countries where diagnostic facilities are minimal. Therefore strategies to improve the awareness and upgrade the diagnostic facilities need to be implemented in near future.

Melioidosis in Sri Lanka

“…As a result of a World Health Organization-supported laboratory-twinning project, additional cases were confirmed in the Central and Western Provinces in 2006 and 2008 [ 17 , 18 ] and surveillance for melioidosis was commenced. Recently, further cases from Sri Lanka, diagnosed locally and overseas, have been published [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].…”

Non-Caseating Granulomatous Infective Spondylitis: Melioidotic Spondylitis

“…Although several reports describe the multisystem involvement of melioidosis in detail [123], few cases of melioidotic spondylitis have been reported [456]. Histopathologically, melioidotic spondylitis presents as a non-caseating, granulomatous inflammation that is frequently confused with tuberculous spondylitis.…”

Neuromelioidosis: Craniospinal MRI Findings in Burkholderia pseudomallei Infection

“…Current understanding of the imaging features of CNS melioidosis is derived from isolated case reports or small case series in the microbiology literature . Variable imaging manifestations have been reported and include cerebral abscesses, meningitis, extraaxial collections, and skull osteomyelitis.…”

“…5 Current understanding of the imaging features of CNS melioidosis is derived from isolated case reports or small case series in the microbiology literature. [5][6][7][8][9][10][11][12][13][14][15][16][17][18] Variable imaging manifestations have been reported and include cerebral abscesses, meningitis, extraaxial collections, and skull osteomyelitis. To our knowledge, we present the largest series documenting the specific neuroimaging findings of culture-confirmed CNS melioidosis.…”