Observations placeholder

BMJ Case Rep. 2013; 2013: bcr2013009655.
Published online 2013 Apr 18. doi:  10.1136/bcr-2013-009655
PMCID: PMC3645595
PMID: 23605844
Case Report;  Melioidosis in a returning traveller
Alaa Ismail,1 Adam Buckley,1 and Simon William Dubrey2

Abstract

A 66-year-old man returned to the UK from Thailand with a 2-week history of new confusion, hallucinations, fever with rigours and productive cough. He had not responded to (unspecified) antibiotic treatment in Thailand. On examination he was afebrile, with an abbreviated mental test score of 8/10 and no other findings on systemic examination. He was treated with ceftriaxone in response to discovery of a Gram-negative organism in blood. This was converted to meropenem on the clinical suspicion of our microbiologist, on the basis of a history of contact with surface water in the Far East. A blood culture subsequently confirmed Burkholderia pseudomallei. His condition remained stable for approximately 4 days, but then deteriorated over the course of the next 2 weeks with pneumonia and subsequent formation of disseminated abscesses. Treatment was withdrawn as his condition deteriorated to the point at which survival was deemed impossible and he subsequently died.

Background

Burkholderia pseudomallei septicaemia (melioidosis) has a mortality as high as 90% if untreated,1 and around 20% in developed regions with appropriate treatment.2

Mortality is particularly high in immunocompromised groups, for example, patients with diabetes mellitus. While usually recognised promptly in endemic areas, it may go unrecognised in areas in which it is uncommon.

Given the increase in tourism to endemic areas, often by people in late middle age, we expect an increase in presentations within the UK and are concerned about the ramifications of a missed diagnosis.

In case of our patient, although his diagnosis and initiation of treatment on clinical grounds was reasonably prompt, it could easily have gone unrecognised for longer owing to the unusual organism and recognised difficulties (specific growth media required) in obtaining a definitive microbiological diagnosis.

Case presentation

A 66-year-old man returned to the UK from the Phuket region of Thailand with a 2-week history of new confusion, hallucinations, fever with rigours and productive cough. He had not responded to (unspecified) antibiotic treatment in Thailand. He was previously fit and healthy with no significant medical history.

On examination he was afebrile, with an abbreviated mental test score of 8/10 and no other findings on systemic examination.

Accompanying family members were the primary historians.

The patient did not show any clinical improvement on either empirical treatment with ceftriaxone or subsequent ‘appropriate’ treatment with intravenous meropenem. His confusion was persistent and observations showed intermittent spikes in temperature, desaturations requiring daily increases in oxygen supply and a tachypnoea maintained at 24/min. Arterial blood gas sampling was in keeping with a type 1 respiratory failure, showing a partial pressure of oxygen concentration of 70 mm Hg.

Given his rapid decline he was transferred to an intensive care unit...........................

Outcome and follow-up

Given the aggressive nature of this case of melioidosis, with rapid dissemination and antibiotic resistance, a multidisciplinary team of infectious disease and intensive care clinicians deemed no further intervention to be of benefit.

After the third CT scan of the chest, the Glasgow Coma Scale had reached a score of 7/15. Multiorgan system failure developed and despite best efforts, the patient died 5 weeks from onset of symptoms.