Melioidosis is an infectious disease caused by the Gram-negative bacteria Burkholderia pseudomallei. Several forms of melioidosis are seen clinically such as pulmonary, hematogenous, disseminated and localized forms but pneumonia is a common feature in [1]. Symptoms depend on the form of the infection and include a cough, fever, chest pain and dyspnea in the pulmonary type; fever, headache, seizures, arthralgias, myalgias and abdominal pain in the disseminated type; and fever, headache, dyspnea, arthralgia, confusion and abdominal pain in the hematogenous type.

The presentation has been reported to vary based on the age and comorbidities of the patients as well as on the geographical region in which the patients are located [1]. For example, a higher incidence of genitourinary infection, prostatic abscesses, and encephalomyelitis syndrome in Australian patients have been reported versus liver- splenic abscesses and suppurative parotitis with facial palsy in Thai patients [2] [3]. The encephalomyelitis syndrome is characterized by brainstem involvement with flaccid paralysis and is associated with high rates of morbidity and mortality [4]. Dermatological and soft tissue manifestations of melioidosis resemble necrotizing fasciitis [5]. Other manifestations like thyroid and genital abscesses, ocular involvement with corneal ulcers and orbital cellulitis as well as endocarditis and myocardial abscesses have also been reported [6] [7] [8] [9].

Risk factors associated with a higher incidence of melioidosis include diabetes mellitus [6] [10] [11] [12], thalassemia, chronic renal disease, exposure to infected water [11], steroid usage [11], chronic obstructive lung disease, and chronic use of kava and alcohol [6]. The majority of these risk factors are associated with neutrophil dysfunction which has been implicated in the pathophysiology of melioidosis [6] [12] [13].

• Fever

  Symptoms depend on the form of the infection and include a cough, fever, chest pain and dyspnea in the pulmonary type; fever, headache, seizures, arthralgias, myalgias and abdominal pain in the disseminated type; and fever, headache, dyspnea, arthralgia [symptoma.com]

  The first patient was a young diabetic male presenting to us with history of prolonged fever and upper abdominal discomfort, subsequently diagnosed as a case of pyogenic liver abscess. [ncbi.nlm.nih.gov]

  High fever, hypotension, tachypnea, a bright erythematous flush, and cyanosis are present. Muscle tenderness may be striking. Signs of arthritis or meningitis sometimes occur. [msdmanuals.com]

  Multisystemic melioidosis in a 58-year-old Thai man with no underlying disease who presented with epigastric pain and fever. [doi.org]

• Fatigue

  They presented with fever, rigors, dyspnea, fatigue, diaphoresis, productive cough, and skin abscesses. Six of the seven patients were also hyponatremic. B. pseudomallei was cultured from the blood of six patients and the sputum of one patient. [ncbi.nlm.nih.gov]

  Dyspnea, fatigue, diaphoresis, productive cough, and skin abscesses were commonly co-occurring symptoms ( S1 Table ). [journals.plos.org]

  Pailat Ganjanarak found it increasingly difficult to ignore the fatigue, chills and vomiting, so he went for a massage, a common cure-all for mild illnesses in this part of Thailand. It didn’t help. [independent.co.uk]

  Common symptoms of problems in the immune system include fatigue, joint pain, skin rash, abdominal pain or digestive issues, fever, swollen glands, repeated infections, or headaches. [rarediseases.info.nih.gov]

• Malaise

  He denied fevers, chills, malaise, abdominal pain, or shortness of breath but did admit to 40 lb of weight loss over the past 2 years despite increased food intake. [doi.org]

  He was admitted to hospital in June with fever (39°C), dyspnea, anorexia, malaise, abdominal pain, and diarrhea ( S1 Table ). Upon admission, he was tachycardic (128 bpm) and tachypneic (28 breaths per minute). [journals.plos.org]

• Fever of Unknown Origin

  Given the high mortality of neonatal melioidosis, particular attention must be paid when the caretakers of the newborn develop fever of unknown origin in a melioidosis-endemic region. [ncbi.nlm.nih.gov]

  Therefore, detection of splenic abscesses alone is suggestive of melioidosis, especially in those with comorbid diseases or in patients living or travelling in endemic areas who present with fever of unknown origin, abdominal pain or discomfort. [doi.org]

• Cough

  All patients presenting with fever and non-specific symptoms like a cough should be thoroughly and quickly investigated as they can rapidly deteriorate depending on the cause. [symptoma.com]

  The time from infection to acute disease ranges from one to 21 days and symptoms can vary greatly, from fever, cough and breathing difficulties in early stages through to severe pneumonia and sores that will not heal. [abc.net.au]

  Two years later, the father developed cough and fever again, and the same novel sequence type of B. pseudomallei was isolated from the blood of the father. [ncbi.nlm.nih.gov]

• Pleural Effusion

  A 44-year-old Caucasian man developed pneumonia, with bilateral pleural effusions and complicated by a hemodynamically significant pericardial effusion, soon after his return from Thailand to Switzerland. [ncbi.nlm.nih.gov]

  Nodular lesions, thin-walled cysts, and pleural effusion may also occur. The WBC count ranges from normal to 20,000/ μ L. [msdmanuals.com]

  Pneumonia, pulmonary abscesses, and pleural effusions can occur. The incubation period is 10-14 days. With inhalational melioidosis, cutaneous abscesses may develop and take months to appear. [emedicine.medscape.com]

• Productive Cough

  A 42-year-old man was admitted with a non-productive cough, dyspnea, myalgia, diffuse abdominal pain. Pulmonary auscultation revealed a vesicular murmur, snoring sounds, and the presence of basal crackling rales in the left hemithorax. [ncbi.nlm.nih.gov]

  The latter may mimic tuberculosis, with fever, weight loss, productive cough, and upper lobe infiltrate, with or without cavitation. More than 50% of cases present with pneumonia. [wwwnc.cdc.gov]

  In July 2001, he was admitted to a hospital in New Zealand with fever, productive cough, and decreased pulmonary function. Pseudomonas aeruginosa, Staphylococcus aureus, and B. pseudomallei were isolated from a sputum sample. [doi.org]

• Tachypnea

  High fever, hypotension, tachypnea, a bright erythematous flush, and cyanosis are present. Muscle tenderness may be striking. Signs of arthritis or meningitis sometimes occur. [msdmanuals.com]

  On the third postoperative day, she developed acute-onset tachypnea, and a chest X-ray showed changes of acute respiratory distress syndrome (see Figures 3, 4 and 5). The patient was intubated and treated with parenteral meropenem. [the-rheumatologist.org]

  Sepsis was diagnosed [ 10 ] if ⩾2 of the following findings was present: (1) a body temperature >38°C or 90 beats/min); (3) tachypnea (respiratory rate >20 breaths/min or Paco 2 12,000 cells/mm 3 or band form >10%; (5) organ dysfunction, indicated by [doi.org]

• Rales

  Pulmonary signs may be absent or may include rales, rhonchi, and pleural rubs. Localized suppurative infection can occur in almost any organ but is most common at the site of inoculation in the skin (or lungs) and associated lymph nodes. [msdmanuals.com]

  Pulmonary auscultation revealed a vesicular murmur, snoring sounds, and the presence of basal crackling rales in the left hemithorax. [ncbi.nlm.nih.gov]

  Cough, tachypnea, and rales are characteristic. Sputum may be blood-tinged. Chest x-rays usually show upper lobe consolidation, frequently cavitating and resembling tuberculosis. [merckmanuals.com]

  Auscultation revealed rales in both lungs, and chest radiography ( Fig 2 ) confirmed lobar pneumonia. [journals.plos.org]

• Abdominal Pain

  confusion and abdominal pain in the hematogenous type. [symptoma.com]

  A 33-year-old male, who had been treated for pulmonary tuberculosis and multiple splenic abscesses four years previously, presented with a five-day history of acute-onset high-grade fever, abdominal pain and distension, and dyspnea. [ncbi.nlm.nih.gov]

• Chest Pain

  We report a case of a 55-year-old woman with a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy for ovarian mucinous cystadenocarcinoma five years back, who presented with complaints of chest pain, abdominal distention, and [ncbi.nlm.nih.gov]

  Symptoms depend on the form of the infection and include a cough, fever, chest pain and dyspnea in the pulmonary type; fever, headache, seizures, arthralgias, myalgias and abdominal pain in the disseminated type; and fever, headache, dyspnea, arthralgia [symptoma.com]

  Localized Infection: Localized pain or swelling Fever Ulceration Abscess Pulmonary Infection: Cough Chest pain High fever Headache Anorexia Bloodstream Infection: Fever Headache Respiratory distress Abdominal discomfort Joint pain Disorientation Disseminated [cdc.gov]

  Onset may be abrupt or gradual, with headache, anorexia, pleuritic or dull aching chest pain, and generalized myalgia. Fever is usually > 39 ° C. Cough, tachypnea, and rales are characteristic. Sputum may be blood-tinged. [msdmanuals.com]

• Hepatomegaly

  On presentation she had high fever and tender hepatomegaly. Ultra Sound Scan of abdomen showed multiple liver and splenic abscesses. [ncbi.nlm.nih.gov]

  Most of the patients had signs of right-sided heart failure (ie, neck vein engorgement, hepatomegaly, and leg edema). One patient presented with cardiac tamponade. [doi.org]

• Myalgia

  Symptoms depend on the form of the infection and include a cough, fever, chest pain and dyspnea in the pulmonary type; fever, headache, seizures, arthralgias, myalgias and abdominal pain in the disseminated type; and fever, headache, dyspnea, arthralgia [symptoma.com]

  A 42-year-old man was admitted with a non-productive cough, dyspnea, myalgia, diffuse abdominal pain. Pulmonary auscultation revealed a vesicular murmur, snoring sounds, and the presence of basal crackling rales in the left hemithorax. [ncbi.nlm.nih.gov]

  Onset may be abrupt or gradual, with headache, anorexia, pleuritic or dull aching chest pain, and generalized myalgia. Fever is usually > 39 ° C. Cough, tachypnea, and rales are characteristic. Sputum may be blood-tinged. [msdmanuals.com]

  Onset may be abrupt or gradual, with headache, anorexia, pleuritic or dull aching chest pain, and generalized myalgia. Fever is usually > 39° C. Cough, tachypnea, and rales are characteristic. Sputum may be blood-tinged. [merckmanuals.com]

• Arthralgia

  Symptoms depend on the form of the infection and include a cough, fever, chest pain and dyspnea in the pulmonary type; fever, headache, seizures, arthralgias, myalgias and abdominal pain in the disseminated type; and fever, headache, dyspnea, arthralgia [symptoma.com]

  A 35-year-old previously healthy woman was admitted to the emergency unit of Ramón y Cajal University Hospital, Madrid, Spain, on March 25, 2011, because of a 4-day fever and arthralgias. [doi.org]

  Symptoms of acute melioidosis include fever, cough, pleurisy, arthralgia, myalgia, headache, anorexia, and night sweats. Melioidosis may present in many ways, ranging from acute or chronic localized infections to sepsis. [ncbi.nlm.nih.gov]

  Patient 6 was a previously healthy 24-year-old male factory worker from Koh Kong Province ( Fig 1 ) who was admitted to Takeo in December with complaints of fever (39°C), rigors, dizziness, headache, dyspnea, palpitations, cough, arthralgias, myalgias [journals.plos.org]

• Knee Pain

  He gave a history of inability to walk due to knee pain since 1 week. Patient was treated for right knee pain, swelling, and for urinary tract infection in another health-care facility before being referred to our hospital. [ijccm.org]

• Joint Effusion

  (b) Axial fat-suppressed T 2 weighted fast-spin echo MRI shows a right sacroiliac joint effusion (arrowheads), with prominent hyperintense marrow oedema in the adjacent ilium and sacral ala, consistent with right sacroiliitis. [doi.org]

• Cutaneous Manifestation

  Melioidosis is caused by the saprophytic gram-negative bacillus Burkholderia pseudomallei, and has varied presentations, with cutaneous manifestations occurring in about 13% of cases. [omicsonline.org]

• Neck Swelling

  Multisystemic melioidosis in a 41-year-old Malay woman with diabetes mellitus who presented with fever and neck swelling. (a) Frontal radiograph shows prominent sclerosis adjacent to the right sacroiliac joint. [doi.org]

• Headache

  Symptoms depend on the form of the infection and include a cough, fever, chest pain and dyspnea in the pulmonary type; fever, headache, seizures, arthralgias, myalgias and abdominal pain in the disseminated type; and fever, headache, dyspnea, arthralgia [symptoma.com]

  Onset may be abrupt or gradual, with headache, anorexia, pleuritic or dull aching chest pain, and generalized myalgia. Fever is usually > 39 ° C. Cough, tachypnea, and rales are characteristic. Sputum may be blood-tinged. [msdmanuals.com]

  The second patient was a middle aged diabetic complaining of prolonged fever and headache and found to have right frontal lobe brain abscess.The pus cultured from the lesion in both cases showed growth of Burkholderia pseudomallei. [ncbi.nlm.nih.gov]

  Localized Infection: Localized pain or swelling Fever Ulceration Abscess Pulmonary Infection: Cough Chest pain High fever Headache Anorexia Bloodstream Infection: Fever Headache Respiratory distress Abdominal discomfort Joint pain Disorientation Disseminated [cdc.gov]

• Seizure

  Four days later, he developed focal seizures involving the left leg and numbness of the left side. Initial laboratory investigations were suggestive of a bacterial infection. [ncbi.nlm.nih.gov]

  Symptoms depend on the form of the infection and include a cough, fever, chest pain and dyspnea in the pulmonary type; fever, headache, seizures, arthralgias, myalgias and abdominal pain in the disseminated type; and fever, headache, dyspnea, arthralgia [symptoma.com]

• Irritability

  "You might look like you have some skin irritation, ... or you might have an abscess on your liver," says study co-author Stuart Wilson, a molecular biologist at the University of Sheffield in the United Kingdom. "And it's the same disease." [sciencemag.org]

  On arrival at QECH, the child was irritable and pale; temperature was 38.7°C, weight 9.8 kg (weight-for-age z score −1.14), and height 79 cm (weight-for-height z score −1.06). [doi.org]

• Agitation

  17 ] containing 15 g/l tryptone (Oxoid, Australia), 5 mg/l crystal violet and 50 mg/l colistin sulphate (Sigma, Australia) in 500 ml conical Pyrex culture flasks which were sealed (the organism is facultatively anaerobic), then incubated at 37°C with agitation [doi.org]

All patients presenting with fever and non-specific symptoms like a cough should be thoroughly and quickly investigated as they can rapidly deteriorate depending on the cause. History should elicit details of onset, duration, and progression of symptoms along with a specific history of exposure to contaminated source. The physician should inquire regarding recent travel to areas known to be endemic for melioidosis. Dermatological, pulmonary, cardiac, and neurological features of the infection must be looked for on physical examination.

Basic laboratory workup like complete blood count, erythrocyte sedimentation rate (ESR), liver function tests and Gram stain with blood, urine, skin lesion, cerebrospinal fluid, and sputum culture should be ordered in all patients depending on their clinical presentation. Results may reveal anemia, leukopenia, elevated liver enzymes, and elevated urea and creatinine levels. These results along with hypoglycemia and acidosis at presentation are indicators of a poor prognosis [14] [15] [16].

The gold standard for diagnosis is the isolation of Burkholderia pseudomallei from body fluids of infected patients and modified Ashdown's selective medium is used for this purpose [17]. Despite poor sensitivity and specificity, indirect hemagglutination (IHA), is currently the most commonly used test for diagnosis [1].

Chest radiography is performed to detect features of pneumonia or diffuse nodular shadows. Visceral melioidosis can be detected by ultrasonography and computed tomography which may show discrete hepatic and splenic abscesses [18]. In disseminated melioidosis, plain X-rays and magnetic resonance imaging are obtained to detect bone and soft tissue involvement [18].

• Cavitary Lesion

  Examination and investigations revealed left sided consolidation with cavitary lesion, hepato-splenomegaly and sputum analysis confirmed growth of Burkholderia pseudomallei. [ncbi.nlm.nih.gov]

  Chest x-rays usually show irregular, nodular (4 to 10 mm) densities but may also show lobar infiltrates, bilateral bronchopneumonia, or cavitary lesions. [msdmanuals.com]

• Pleural Effusion

  A 44-year-old Caucasian man developed pneumonia, with bilateral pleural effusions and complicated by a hemodynamically significant pericardial effusion, soon after his return from Thailand to Switzerland. [ncbi.nlm.nih.gov]

  Nodular lesions, thin-walled cysts, and pleural effusion may also occur. The WBC count ranges from normal to 20,000/ μ L. [msdmanuals.com]

  Pneumonia, pulmonary abscesses, and pleural effusions can occur. The incubation period is 10-14 days. With inhalational melioidosis, cutaneous abscesses may develop and take months to appear. [emedicine.medscape.com]

• Leukocytosis

  Death from septicemia was associated with failure to develop a leukocytosis or pyrexia over 38 degrees C, azotemia, hypoglycemia, and jaundice. [ncbi.nlm.nih.gov]

  Admission laboratory testing ( Table 1A ) revealed leukocytosis, anemia, hyponatremia, hyperkalemia, and markedly elevated BUN and Cr indicative of acute renal injury. [journals.plos.org]

Delay in the diagnosis, or the initiation of appropriate and effective treatment against melioidosis, could worsen the outcome. [omicsonline.org]

In an era where global travel allows for the spread of melioidosis and other dangerous illnesses beyond their traditionally endemic areas, international treatment protocols have gained additional significance; however, treatment guidelines for melioidosis [reproductivemedicine.com]

Parenteral amoxicillin/clavulanate is a safe and effective initial treatment, but parenteral ceftazidime remains the treatment of choice for severe melioidosis. [ncbi.nlm.nih.gov]

[…] bacteremia after ⩾7 days of antibiotic treatment, and (c) switch of therapy ⩾72 h after commencement of treatment in response to clinical failure (persistent fever or new foci of infection that developed during treatment). [doi.org]

This will expedite diagnosis and prompt treatment leading to an excellent prognosis. [ncbi.nlm.nih.gov]

These results along with hypoglycemia and acidosis at presentation are indicators of a poor prognosis. [symptoma.com]

The disease can result in sepsis, and the prognosis once the disease progresses to this stage is very poor. [house.wikia.com]

This case highlights the possibility of leptospirosis and melioidosis co-infections and their underlying challenges in the rapid and accurate detection of the etiologic microorganism. [ncbi.nlm.nih.gov]

Bisen, Ruchika Raghuvanshi, Emerging Epidemics: Management and Control, unnumbered page, Melioidosis is the etiological designation of a spectrum of clinical manifestations caused by the gram-negative bacillus Burkholderia pseudomallei. 2015, Jeremy Hull [en.wiktionary.org]

His research interests include epidemiology of infectious diseases, public health policy, and health services. Top Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev. 2005 ; 18 : 383 – 416. [doi.org]

Melioidosis is a long-known disease since 1912, but only quite recently we have obtained the knowledges about its actual clinical and epidemiological features. [ncbi.nlm.nih.gov]

Diagnosis is based on clinical and epidemiological features as well as bacterial culture. Treatment requires long-term intravenous and oral antibiotic courses. [utmb.influuent.utsystem.edu]

The majority of these risk factors are associated with neutrophil dysfunction which has been implicated in the pathophysiology of melioidosis. [symptoma.com]

Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev 2005 ; 18 : 383 – 416 4 Chantratita, N, Wuthiekanun, V, Limmathurotsakul, D, Vesaratchavest, M, Thanwisai, A, Amornchai, P et al. [cambridge.org]

Melioidosis: epidemiology, pathophysiology and management. Clin Microbiol Rev 2005; 18: 383-416. Heymann D (Ed). 2008. Control of Communicable Diseases Manual, 19th edition. American Public Health Association: Washington. [health.qld.gov.au]

Melioidosis: epidemiology, pathophysiology and management .Clin Microbiol Rev. 2005 ;18: 383 - 416 Google Scholar | Crossref | Medline Brett P.J. ,Woods D.E.. [doi.org]

[…] and Control 8, Udon Thani 41000, Thailand 22 The Office of Disease Prevention and Control 10, Ubon Ratchathani 34000, Thailand 23 The Office of Disease Prevention and Control 12, Songkla 90000, Thailand 24 Mahidol University Amnatcharoen Campus, Amnatcharoen [mdpi.com]

Most participants saw no harm in not adopting recommended preventive behaviours, and perceived rubber boots and gloves to be hot and uncomfortable while working in muddy rice fields. [ncbi.nlm.nih.gov]

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