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Melioidosis is an emerging zoonosis, due to Burkholderia pseudomallei, which is a highly invasive, resistant, and resilient soil bacteria, transmitted by cutaneous or airborne route, and is a potential weapon for bioterrorism. Although the agent has been identified all over the world, the human disease is endemic only in SE Asia and Northern Australia, and gained recent interest after the December 2004 tsunami. Human infection can be a very severe systemic disease (mortality 20 to 80%), with protean expression, but the lung is the most affected organ (50%). Pathophysiology remains unclear. Diabetes mellitus is a major risk factor, and is present in half the Asian patients with melioidosis. Recommended antibiotic regimens are expensive, and in severe disease should be prolonged to 20 weeks to reduce the risk of relapse. Prospects for prevention are limited, and no vaccine is available yet.
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PMID:[Melioidosis]. 1625 57

A 5 year retrospective review of cases of melioidosis was carried out in Sultanah Aminah Hospital, Johor Bahru. There were 44 new cases of melioidosis which was proven by either blood or pus culture growing Burkholderia pseudomallei from the period between January 1999 and December 2003. Of these, 38 (86.4%) were males compared to only 6 (13.6%) females. Thirty-one (70.5%) were Malays, 7 (15.9%) were Chinese, 5 (11.4%) were Indians and 1 (2.2%) was a Sarawakian. The peak age group was between 50 and 59 years (31.8%). Out of these 44 new cases, only 32 medical records could be retrieved and analysed. Twenty-four out of 32 patients (75%) analysed had diabetes mellitus, 4 had chronic or end stage renal failure (CRF/ESRF) and only 1 had Human Immunodeficiency Virus (HIV). One case of "near drowning" was also recorded. Twenty-one out of 44 patients or 47.7% died, of which 8 (38.1%) died within 24 hours of admission. Pulmonary involvement was recorded in 62.6% of the patients but many had signs and symptoms of multiorgan involvement.
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PMID:Melioidosis: the Johor Bahru experience. 1651 1

Melioidosis which is infection with Burkholderia pseudomallei, is an important cause of sepsis in India, southeast Asia and northern Australia. Mortality is high and treatment is problematic. Neurological melioidosis is unusual but meningoencephalitis, encephalomyelitis and brain microabscess can occur Dural sinus thrombosis is not an uncommon cerebrovascular disorder with various etiologies. Hypercoagulable state, pregnancy, dehydration, certain blood dyscrasia and contraceptive pills are common causes however meningitis and local head & neck infections may lead to this condition. Dural sinus thrombosis complicating septicemic melioidosis has never been reported. The authors report a 42-year-old Thai man suffering from septicemic melioidosis with dural sinus thrombosis. He had high fever, headache, left hemiparesis, focal seizure and increased intracranial pressure. Diabetes and mild alcoholic cirrhosis were diagnosed in this admission. CT scan, MRI brain and MRV revealed superior saggital sinus thrombosis with complicating venous infarction over right posterior parietal lobe. Hemoculture demonstrated Burkholderia pseudomallei and CSF was acellular Investigations for causes of dural sinus thrombosis were all negative. This patient gradually improved after treatment with ceftazidime, antiepileptic drug and heparin without clinical recurrence. Neuromelioidosis is a rare syndrome that may present as brain abscess, encephalitis or meningoencephalitis. The authors report dural sinus thrombosis associated with septicemic melioidosis. The authors' hypothesis of venous thrombosis in the presented case is sepsis induced hypercoagulable state. Physicians should be aware of cerebral venous thrombosis in case of suspicious melioidosis with neurological involvement. Prompt treatment with intravenous heparin and antibiotic is potentially effective.
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PMID:Dural sinus thrombosis in melioidosis: the first case report. 1657 13

We describe a case of septic arthritis and bacteremia caused by Burkholderia pseudomallei, a bacterium that is endemic in East Asia and northern Australia. We believe that dissemination occurred in our patient after surgical excision of a pulmonary nodule. Bacteremic melioidosis can present with musculoskeletal involvement in 2-10% of patients, but septic arthritis is uncommon. A review of the literature shows a total of 66 patients reported with septic arthritis caused by this organism. Patients with septic arthritis caused by Burkholderia pseudomallei were likely to have diabetes mellitus, and the knee is the joint most frequently affected by this organism. Recommended initial treatment consists of ceftazidime, alone or in combination with trimethoprim/sulfamethoxazole, high dose imipenem/cilastatin, or high dose cefoperazone/sulbactam. This is followed by a 12-20 week course of oral therapy (based on susceptibilities) to eradicate the organism. Most patients with subacute or latent disease do well after full antibiotic treatment, but relapses are common if full treatment is not given. Awareness of this disease is important even in areas outside of Asia given the increasing frequency of international travel and the growing likelihood of imported cases, along with an aging population of Vietnam veterans and immigrants.
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PMID:Septic arthritis caused by Burkholderia pseudomallei: case report and review of the literature. 1703 42

Melioidosis is a tropical disease caused by infection with the bacterium Burkholderia pseudomallei. Most cases present as an acute febrile illness with severe pneumonia and sepsis. Sub-acute and late onset disease can also occur Melioidosis has been diagnosed among travellers who contracted the disease while staying in endemic areas during the rainy season. We report a case of travel-associated B. pseudomallei cutaneous infection in a febrile 90-year-old woman with diabetes mellitus, with early stage manifestations of an isolated inoculation lesion. A 32 weeks' treatment with oral amoxicillin-clavulanate and doxycycline combination regimen led to resolution of the lesion and lack of relapse over fifteen months of follow-up. Melioidosis should be considered in the differential diagnosis of unusual subacute cutaneous lesions in a febrile patients returning from endemic areas, as successful management largely depends on early diagnosis and specific long-term suppressive antimicrobial therapy at an early stage of the course of the disease.
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PMID:Imported melioidosis with an isolated cutaneous presentation in a 90-year-old traveller from Bangladesh. 1740 88

Burkholderia pseudomallei, the causative agent of melioidosis, is endemic in southeast Asia and northern Australia. In recent years, the incidence of melioidosis has increased worldwide. Septic arthritis is a rare but well-recognized manifestation of melioidosis. Patients with underlying medical conditions, such as diabetes mellitus, renal impairment, cirrhosis, and malignancy are at greater risk. The presentations of melioidotic septic arthritis often mimic other disease processes and patients may not always be clinically septic. We present a case of septic arthritis due to B. pseudomallei in a 66-year-old male with diabetes mellitus presenting with a history of fever and ankle swelling. Follow-up ankle X-ray showed soft tissue swelling. Synovial fluid and blood samples grew B. pseudomallei. The patient improved gradually after parenteral administration of ceftazidime (2 g 8-hourly) and cotrimoxazole (1440 mg 8-hourly). He was discharged on oral cotrimoxazole (1440 mg 12-hourly), doxycycline (100 mg 12-hourly), and chloramphenicol (500 mg 6-hourly) for 6 months. This case highlights the possible occurrence of melioidotic septic arthritis, and the importance of prompt initiation of appropriate antimicrobials to achieve good outcomes.
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PMID:Melioidotic septic arthritis: a case report and literature review. 1744 69

A 65-year-old man with diabetes mellitus reporting fever and urination disturbance on a flight from Bangkok back to Japan in July 2003 was admitted elsewhere for acute prostatitis. Despite intravenous antibiotics, his condition deteriorated. On admission to our hospital, he suffered from respiratory failure, with laboratory data showing disseminated intravascular coagulation (DIC). Computed tomography (CT) shows infiltrative and nodular shadows in both lung fields and low-density areas in the left kidney and prostate gland, consistent with pneumonia and abscesses in these organs. He also developed broad osteomyelitis in the right lower extremity with cellulitis and arthritis in the right hand, knee, and foot. Blood, urine, and joint fluid culture all yielded Burkholderia pseudomallei, so he was diagnosed with melioidosis. Treatment was started with meropenem and minocycline, then meropenem was changed to imipenem. His symptoms gradually improved after ciprofloxacin was added, so all intravenous antibiotics were discontinued and he underwent oral treatment with chloramphenicol, minocycline, and sulfamethoxazole/trimethoprim in September 2003. He developed fever again, however, and oral therapy was discontinued and intravenous antibiotics restarted. After resolution of fever, oral maintenance therapy was initiated again with levofloxacin and minocycline in October, and his condition remained stable. After discharge in April 2004, he has been followed up with no evidence of relapse. This is considered to be the seventh case of melioidosis reported in Japan. Our patient manifested multiple organ lesions with sepsis and DIC, and was difficult to treat, but clinical symptoms improved in long-term antibiotic administration. With travelers to Southeast Asia increasing, greater attention must be paid to imported infectious diseases, such as melioidosis.
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PMID:[A Japanese case of melioidosis presenting as multiple organ lesions accompanied by sepsis and disseminated intravascular coagulation, after a visit to Thailand]. 1756 19

Clinico-microbiological analysis of a series of 25 patients with culture proven melioidosis was done. All patients came from the coastal regions of Kerala and Karnataka and presented between June 2005 to July 2006. They were analysed with respect to clinical presentation, occupation, epidemiology and microbiological features. No single presenting clinical feature was found to be typical of melioidosis. The disease was found to mimic a variety of conditions, including tuberculosis and malignancy. Burkholderia pseudomallei was isolated from blood, sputum, pus, urine, synovial, peritoneal and pericardial fluids. Diabetes mellitus was the most common predisposing factor and 80% of the cases presented during the Southwest monsoon (June to September). It is probable that melioidosis is highly prevalent in western coastal India and yet, greatly underestimated. Better awareness, both among clinicians and microbiologists, coupled with improved diagnostic methods to allow early diagnosis and hence early treatment, will significantly reduce the morbidity and mortality associated with this disease.
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PMID:Melioidosis: an under-diagnosed entity in western coastal India: a clinico-microbiological analysis. 1790 43

Burkholderia pseudomallei is the causative agent of melioidosis. One of the main risk factors for B. pseudomallei infection in endemic areas is diabetes mellitus. The present study investigated IL-17 mRNA and protein expression by peripheral blood mononuclear cells in response to B. pseudomallei infection in 10 diabetic patients in comparison to 10 healthy blood donors. The IL-17 expression in diabetic patients was significantly lower (p < 0.05) than in the controls. However, IL-23 mRNA expression of the 2 groups was comparable. The present findings suggest that melioidosis affects T cell IL-17 production and that patients with diabetes mellitus have a defective IL-17 production in response to this type of infection.
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PMID:Reduced interleukin-17 expression of Burkholderia pseudomallei-infected peripheral blood mononuclear cells of diabetic patients. 1859 31

The gram-negative bacillus Burkholderia pseudomallei is a saprophyte and the cause of melioidosis. Natural infection is most commonly reported in northeast Thailand and northern Australia but also occurs in other parts of Asia, South America, and the Caribbean. Melioidosis develops after bacterial inoculation or inhalation, often in relation to occupational exposure in areas where the disease is endemic. Clinical infection has a peak incidence between the fourth and fifth decades; with diabetes mellitus, excess alcohol consumption, chronic renal failure, and chronic lung disease acting as independent risk factors. Most affected adults ( approximately 80%) in northeast Thailand, northern Australia, and Malaysia have >/=1 underlying diseases. Symptoms of melioidosis may be exhibited many years after exposure, commonly in association with an alteration in immune status. Manifestations of disease are extremely broad ranging and form a spectrum from rapidly life-threatening sepsis to chronic low-grade infection. A common clinical picture is that of sepsis associated with bacterial dissemination to distant sites, frequently causing concomitant pneumonia and liver and splenic abscesses. Infection may also occur in bone, joints, skin, soft tissue, or the prostate. The clinical symptoms of melioidosis mimic those of many other diseases; thus, differentiating between melioidosis and other acute and chronic bacterial infections, including tuberculosis, is often impossible. Confirmation of the diagnosis relies on good practices for specimen collection, laboratory culture, and isolation of B. pseudomallei. The overall mortality rate of infected persons is 50% in northeast Thailand (35% in children) and 19% in Australia.
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PMID:Management of accidental laboratory exposure to Burkholderia pseudomallei and B. mallei. 1859 17


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