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.


  • 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.”
36-Year-Old Male with Rapidly Worsening Breathlessness and Fever

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…
36-Year-Old Male with Rapidly Worsening Breathlessness and Fever
  • MRI leg confirmed osteomyelitis.
  • Surgical debridement and drainage were performed.
36-Year-Old Male with Rapidly Worsening Breathlessness and Fever

Both blood and pus culture grew Burkholderia pseudomallei.

Final Diagnosis

  • Disseminated Meliodosis.


  • He completed intensive phase therapy with I.V. ceftazaidime and currently on maintenance TMP-SMX.

Quick Take-Aways

36-Year-Old Male with Rapidly Worsening Breathlessness and Fever
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.


  1. 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.
  2. 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.

Discover CME INDIA:

Discover CME INDIA