CME INDIA Case Presentation by Dr. V. Nagarjuna Maturu, Consultant Pulmonology and Sleep Medicine at Yashoda Hospitals, Hitec City, Hyderabad.
CME INDIA Case Study
How Presented?
- 36-year male, farmer, presented with 10 days history of rapidly worsening breathlessness and fever.
- He was in respiratory failure at presentation requiring 5 lpm oxygen.
- He also had worsening pain in right leg for a month’s duration.
Investigations
- Detected having diabetes with a HbA1c of 13%.
- HRCT chest performed outside showing multiple nodules in all lung fields with several of them having the characteristic “Feeding vessel sign.”
Provisional Diagnosis
- A possibility of septic embolism versus vasculitis was considered… Vasculitis workup was negative.2d echo (TTE and TEE) did not show any vegetation…
- MRI leg confirmed osteomyelitis.
- Surgical debridement and drainage were performed.
Both blood and pus culture grew Burkholderia pseudomallei.
Final Diagnosis
- Disseminated Meliodosis.
Course
- He completed intensive phase therapy with I.V. ceftazaidime and currently on maintenance TMP-SMX.
Quick Take-Aways
| 1. When feeding vessel sign is identified, consider a hematogenous spread of disease. |
| 2. Blood cultures (as opposed to bronchoscopy) have a high positivity rate in cases with a feeding vessel sign. |
| 3. Melioidosis, an emerging infectious disease in India. |
| 4. It is well known for its protean clinical manifestations. |
| 5. Definitive diagnosis can be made by isolation of non-fermentative Gram-negative bacilli from clinical specimens and identification of the isolate at the species level. |
CME INDIA Learning Points
- Melioidosis is a rare disease caused by Burkholderia pseudomallei, which is common in the soils of tropical islands, mostly in Southeast Asia.
- Its presentation is diverse, management depends on the severity of the spread of bacteria and prognosis is generally good.
- The predominant mode of transmission is through percutaneous inoculation of contaminated wet season soil or water through eating freshwater fish.
- It primarily affects older adults (40–50 years old) but can also affect children.
- Although healthy individuals may have fulminant Melioidosis, severe disease and mortalities are uncommon without risk factors.
- Feeding vessel sign: It consists of a distinct vessel leading directly to a nodule or a mass.
- This sign indicates either that the lesion has a hematogenous origin or that the disease process occurs near small pulmonary vessels.
- D/D of Feeding Vessel Sign
| Pulmonary Infarction |
| Angioinvasive Pulmonary Aspergillosis |
| Pulmonary Vasculitis |
| Pulmonary Embolism |
| Pulmonary Arteriovenous Malformation |
| Pulmonary Metastases |
| Arteriovenous Malformations |
| Septic Pulmonary Emboli |
- Melioidosis is a rare infectious tropical disease caused by Burkholderia pseudomallei (B. pseudomallei)
- It is an environmental saprophyte usually habitating on soils of Southeast Asian fields.
- Usually, cases present with pneumonia and intra-abdominal abscess.
- Diagnosis is established by culture studies from the blood, sputum or abscess drainage.
- Culture is the gold standard of treatment and work-up should include investigation for other areas affected.
- Management relies on culture-guided antibiotic treatment, with good prognosis. Surgical intervention is required in cases not responsive to medical management.
- Most of these patients recovered with administration of intravenous antibiotics, primarily Ceftazidime and Trimethoprim-Sulfamethoxazole.
CME INDIA Tail Piece
- Burkholderia pseudomallei is a gram negative facultative intracellular bacterium causing a disease called Melioidosis.
- It is also known as Whitmore’s Disease.
- This was first described in 1912 by Alfred Whitmore and C. Krishnaswami, seen mostly in Southeast Asia, particularly in Thailand, Singapore, Malaysia and Northern Australia.
References:
- Perez AR, Aburayyan N, Sto Domingo MR Jr, Onglao M. Disseminated Melioidosis presenting as pneumonia, femoral and sacral osteomyelitis, splenic abscess and high rectal fistula: A case report and review of literature. Int J Surg Case Rep. 2021 Dec;89:106588. doi: 10.1016/j.ijscr.2021.106588. Epub 2021 Nov 10. PMID: 34775325; PMCID: PMC8593263.
- Lima L.A.L. Recommendations for the treatment of osteomyelitis | The Brazilian Journal of Infectious Diseases. The Brazilian Journal of Infectious Disease. 2014, September 1;18(5):526–534. doi: 10.1016/j.bjid.2013.12.005.
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