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Melioidosis

Osteomyelitis and Septic Arthritis

Melioidosis or Whitmore's disease is an infectious disease caused by the bacteria Burkholderia pseudomallei. It is mainly a tropical disease with a variable presentation and appears mostly in southeast Asia and northern parts of Australia. The disease spreads to humans through direct contact with a contaminated source.


Presentation

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
  • 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]
  • 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]
  • Abstract This report focuses on a fatality involving severe dengue fever and melioidosis in a 28-year-old truck driver residing in Pacoti in northeastern Brazil.[ncbi.nlm.nih.gov]
  • Multisystemic melioidosis in a 58-year-old Thai man with no underlying disease who presented with epigastric pain and fever.[doi.org]
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]
  • Symptoms of chills, fever and malaise, tenderness in the right axilla, and pleuritic pain in the right side of the chest developed in the worker 3 days later.[doi.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]
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]
Intravenous Drugs
  • Antimicrobial treatment comprises intravenous drugs for at least 10 days, followed by oral drugs for at least 12 weeks. The standard oral regimen based on trial evidence is trimethoprim-sulfamethoxaxole (TMP-SMX) plus doxycycline.[ncbi.nlm.nih.gov]
Cough
  • 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]
  • 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]
  • 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]
  • 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]
  • Case 1: A 39-year-old alcoholic and uncontrolled diabetic male presented with cough, fever, and left focal seizures with secondary generalization.[ncbi.nlm.nih.gov]
Pleural Effusion
  • We report a case of systemic melioidosis in a 58-year-old diabetic, occupationally-unexposed male patient, who presented with chronic fever, sepsis, pneumonia, pleural effusion and subcutaneous abscess, was undiagnosed for long, misidentified as Pseudomonas[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • A 43-year-old Bangladeshi gentleman, known diabetic, hypertensive, smoker, presented with the complaints of recurrent episodes of low to high grade intermittent fever, productive cough with occasional haemoptysis and 10 kg weight loss over one and half[ncbi.nlm.nih.gov]
  • 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]
  • 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 oliguria[doi.org]
  • Sepsis was defined as 2 of the following signs and symptoms clinically ascribed to infection: fever (temperature 38 C or 90 beats/min), tachypnea (respiratory rate 20 breaths/min, PaCO 2 12,000 cells/mL or 10% band forms.[doi.org]
Rales
  • Pulmonary auscultation revealed a vesicular murmur, snoring sounds, and the presence of basal crackling rales in the left hemithorax.[ncbi.nlm.nih.gov]
  • 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]
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]
  • A 45-year-old man with underlying diabetes presented with fever and lethargy for 2 weeks and abdominal pain for 2 days. His liver was enlarged on examination. Blood investigations revealed mild leucocytosis and raised liver enzymes.[ncbi.nlm.nih.gov]
  • 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]
  • CASE PRESENTATION: A 42-year-old woman with diabetes presented with abdominal pain, vomiting and intermittent fever for one month. Six months before presentation she had recurrent skin abscesses.[ncbi.nlm.nih.gov]
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]
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]
  • Some of these symptoms include rapid breathing, chest pain, and dull chest pain. An infected person may also have a high fever, headache and eventually pneumonia. Depending how a person gets infected, there could be long-term problems.[passporthealthglobal.com]
  • The acute form of the infection typically presents as pneumonia with symptoms of fever, cough, chest pain, difficulty breathing, and lack of appetite.[iamat.org]
Myalgia
  • 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]
  • 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]
  • 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]
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]
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]
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.[ncbi.nlm.nih.gov]
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]
  • 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]
  • A healthy 65-year-old female who had been treated with antipsychotic medication for neurotic depression for over 2 years presented with acute-onset fever, headache, lead-pipe rigidity of all limbs, and delirium.[ncbi.nlm.nih.gov]
  • A 42-year-old Sri Lankan male with type 2 diabetes presented with a febrile illness of 6 days with headache and constitutional symptoms. Clinical examination was unremarkable.[ncbi.nlm.nih.gov]
  • This is a case report describing a 14-year-old boy who presented to a remote medical post with acute neurological symptoms (vomiting, severe headache, ataxia, cranial nerve VI and VII palsy) and was referred to the tertiary paediatric hospital in Perth[ncbi.nlm.nih.gov]
Ataxia
  • This is a case report describing a 14-year-old boy who presented to a remote medical post with acute neurological symptoms (vomiting, severe headache, ataxia, cranial nerve VI and VII palsy) and was referred to the tertiary paediatric hospital in Perth[ncbi.nlm.nih.gov]

Workup

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
  • We report a young healthy female who does not have known risk factors or immunocompromised state, presented with bilateral multiple cavitary lesions involving all three zones of the lungs. She used to involve in home gardening.[ncbi.nlm.nih.gov]
  • 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]
  • Chest X-ray is also routinely performed and may show consolidations, cavitary lesions, effusions, empyemas, and multiple lung abscesses. [22] [23] [24] Treatment / Management Patients with significant pulmonary involvement may progress to respiratory[ncbi.nlm.nih.gov]
Leptospira Interrogans
  • Lu PL, Tseng SH: Fatal septicemic melioidosis in a young military person possibly co-infected with Leptospira interrogans and Orientia tsutsugamushi . Kaohsiung J Med Sci 2005; 21: 173–178. PubMed CrossRef Google Scholar 13.[doi.org]
  • Fatal septicemic melioidosis in a young military person possibly co-infected with Leptospira interrogans and Orientia tsutsugamushi. Kaohsiung J Med Sci. 2005 ; 21 : 173 – 8.[doi.org]
Penicillium
  • […] due to other organisms, as follows: Escherichia coli , 7 patients; Klebsiella pneumoniae , 9; Staphylococcus aureus , 7; Salmonella species, 3; Streptococcus pyogenes , 1; Acinetobacter species, 1; Enterococcus species, 1; Pseudomonas aeruginosa , 2; Penicillium[doi.org]
Pleural Effusion
  • We report a case of systemic melioidosis in a 58-year-old diabetic, occupationally-unexposed male patient, who presented with chronic fever, sepsis, pneumonia, pleural effusion and subcutaneous abscess, was undiagnosed for long, misidentified as Pseudomonas[ncbi.nlm.nih.gov]
  • 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]
  • 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]

Treatment

  • The median duration of follow-up in the 45 patients who complied with treatment and were followed for at least 6 months was 28 months (range 6-65). Fluoroquinolone treatment was well tolerated.[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]
  • There were 13 treatment failures (5 failures to respond, 8 relapses), a failure rate of 29% (95% confidence interval 17–43%). The median time to treatment failure was 7 months (range 2–26).[doi.org]
  • Recurrence during treatment and duration of oral treatment were also modeled as time-varying covariates.[doi.org]

Prognosis

  • This will expedite diagnosis and prompt treatment leading to an excellent prognosis.[ncbi.nlm.nih.gov]
  • Acute form of melioidosis predominated, and shock at admission was independently associated with a grave prognosis. Overall, 22% of 58 patients died in hospitals.[ncbi.nlm.nih.gov]
  • The presence of B. pseudomallei in urine during systemic infection is associated with a poor prognosis.[ncbi.nlm.nih.gov]
  • The disease can result in sepsis, and the prognosis once the disease progresses to this stage is very poor.[house.wikia.com]
  • Early recognition and specific therapy can improve prognosis. KEYWORDS: Acute-on-chronic liver failure; Melioidosis; Pancreatitis; Spontaneous bacterial peritonitis[ncbi.nlm.nih.gov]

Etiology

  • 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]
  • […] occupationally-unexposed male patient, who presented with chronic fever, sepsis, pneumonia, pleural effusion and subcutaneous abscess, was undiagnosed for long, misidentified as Pseudomonas aeruginosa infection elsewhere, but was saved due to correct identification of the etiologic[ncbi.nlm.nih.gov]
  • Burkholderia pseudomallei, the etiologic agent of melioidosis, is endemic to tropic regions, mainly in Southeast Asia and northern Australia. Melioidosis occurs only sporadically in travellers returning from disease-endemic areas.[ncbi.nlm.nih.gov]
  • BACKGROUND: The work was undertaken to expand the tools available for researching Burkholderia pseudomallei (Bp), the etiological agent of the tropical disease melioidosis.[ncbi.nlm.nih.gov]
  • Burkholderia pseudomallei , the etiologic agent of melioidosis, is an important but under-recognized cause of disease in the tropics.[ajtmh.org]

Epidemiology

  • 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]
  • In conclusion, the clinical-epidemiological features of melioidosis in Ceará are similar to those of regions where this disease is known to be endemic.[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]
  • Further epidemiological studies are needed to identify risk factors so that optimal strategies for control of melioidosis may be developed.[ncbi.nlm.nih.gov]
  • ISSN: 0950-2688 EISSN: 1469-4409 URL: /core/journals/epidemiology-and-infection[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • 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 Google Scholar Crossref Medline Brett P.J. ,Woods D.E..[doi.org]
  • Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev. 2005 ; 18 : 383 – 416. DOI PubMed White NJ. Melioidosis. Lancet. 2003 ; 361 : 1715 – 22. DOI PubMed Stanton AT, Fletcher W. Melioidosis.[doi.org]
  • Cheng AC, Currie BJ: Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev 2005; 18: 383–416. PubMed CrossRef Google Scholar 19.[doi.org]

Prevention

  • 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]
  • A long course of oral eradication therapy is required to prevent relapse. Studies exploring the role of preventative measures, earlier clinical identification, and better management of severe sepsis are required to reduce the burden of this disease.[ncbi.nlm.nih.gov]
  • In the United States, Bp is listed as a Tier-1 select agent by the Centers for Disease Control and Prevention (CDC), thus requiring high levels of regulation and biosafety level 3 (BSL3) facilities for experimental manipulation of live organisms.[ncbi.nlm.nih.gov]
  • Rinse with an antiseptic cleanser to prevent wound infection. Healthcare and agricultural workers should wear protective gear to help prevent infection. If you suspect that you have Melioidosis, seek medical attention immediately.[iamat.org]

References

Article

  1. Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clini Microbiol Rev. 2005;18(2):383-416
  2. Vatcharapreechasakul TY. Suputtamongkol DA, Dance DA, et al. Pseudomonas pseudomallei liver abscesses: a clinical, laboratory, and ultrasonographic study. Clin. Infect. Dis. 1992;14:412-417.
  3. Dance DA, Davis TM, Wattanagoon Y, et al. Acute suppurative parotitis caused by Pseudomonas pseudomallei in children. J. Infect. Dis. 1989;159:654-660.
  4. Currie BJ, Fisher DA, Howard DM, Burrow JN. Neurological melioidosis. Acta Trop. 2000;74:145-151.
  5. Wang YS, Wong CH, Kurup A. Cutaneous melioidosis and necrotizing fasciitis caused by Burkholderia pseudomallei. Emerg. Infect. Dis. 2003; 9:1484-1485.
  6. Currie BJ, Fisher DA, Howard DM, et al. Endemic melioidosis in tropical northern Australia: a 10-year prospective study and review of the literature. Clin. Infect. Dis. 2000; 31:981-986.
  7. Wong PK, Ng PH. Melioidosis presenting with orbital cellulitis. Singapore Med. J. 1996;37:220-221
  8. Punyagupta S. Melioidosis. Review of 686 cases and presentation of a new clinical classification, p. 217-229. In S. Punyagupta, T. Sirisanthana, and B. Stapatayavong (ed.), Melioidosis. Bangkok Medical Publisher, Bangkok, Thailand; 1989
  9. Baumann BB, Morita ET. Systemic melioidosis presenting as myocardial infarct. Ann. Intern. Med. 1967; 67:836-842.
  10. Merianos AM, Patel JM, Lane CN et al. The 1990-1991 outbreak of melioidosis in the Northern Territory of Australia: epidemiology and environmental studies. Southeast Asian J. Trop. Med. Public Health. 1993; 24:425-435.
  11. Suputtamongkol Y, Chaowagul W, Chetchotisakd P, et al. Risk factors for melioidosis and bacteremic melioidosis. Clin. Infect. Dis. 1999; 29:408-413.
  12. Suputtamongkol YA, Hall J, Dance DA, et al. The epidemiology of melioidosis in Ubon Ratchatani, northeast Thailand. Int. J. Epidemiol. 1994; 23:1082-1090.
  13. Jones AL, Beveridge TJ, Woods DE. Intracellular survival of Burkholderia pseudomallei. Infect. Immun. 1996; 64:782-790.
  14. Chaowagul W, White NJ, Dance DA, et al. Melioidosis: a major cause of community-acquired septicemia in northeastern Thailand. J. Infect. Dis. 1989;159:890-899.
  15. Cheng AC, Jacups SP, Anstey NM, Currie BJ. A proposed scoring system for predicting mortality in melioidosis. Trans. R. Soc. Trop. Med. Hyg. 2003;97:577-581.
  16. Currie BJ, Howard DM, Nguyen VT, et al. The 1990-1991 outbreak of melioidosis in the Northern Territory of Australia: clinical aspects. Southeast Asian J. Trop. Med. Public Health 1993;24:436-443.
  17. Dance DA, Wuthiekanun V, Naigowit P, White NJ. Identification of Pseudomonas pseudomallei in clinical practice: use of simple screening tests and API 20NE. J. Clin. Pathol. 1989; 42:645-648.
  18. Muttarak M, Peh WC, Euathrongchit J, et al. Spectrum of imaging findings in melioidosis. Br J Radiol. 2009; 82 (978): 514-521.

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Last updated: 2019-07-11 22:29