Melioidosis

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pathogen

• Burkholderia pseudomallei
• potential biological weapon

epidemiology

• endemic South Asia, Southeastern Asia and Australia
  • especially in Northeastern Thailand and Northern Australia
  • Third ID death in Northeaster Thailand following after HIV and TB
• reason of localized distributions are unknown
• highly seasonal, most in rainy season
  • stormy weather events like typhoon

transmission

• Burkholderia pseudomallei lives in soil and water
• close and repetitive contact to soil and freshwater, especially occupationally
  • rice farmers in Thailand, Aboriginals in Australia
• most of cases unclear contact history
• immersion in freshwater or aspiration of freshwater like in tsunami may cause infection
• outbreak case mediated by contaminated water supply, disinfectant or detergents

incubation period

• 1-21 days after apparent exposure
  • mean 9 days
• rarely long latency
  • a case of 62 years after exposed in Viet Nam
    • "Vietnamese time-bomb"
  • keep latent in macrophage for long time
    • rational of long-term maintenance oral treatment
  • where Burkholderia-containing macrophages are kept in human body is still unknown

risk factors

• 60-90% of cases have underlying conditions
• especially diabetes mellitus and chronic renal failure
  • steroid, alcohol abuse, liver dysfunction, chronic lung disease, etc.
• HIV never predisposes to melioidosis

clinical course

• peak in 40-60 y/o
• male > female, presumably difference of exposure activity
• most asymptomatic or mild non-specific
  • 60-70% of endemic area population show seroconversion until 4 y/o
• apparent case shows sepsis with fever and rigor
  • 80% of apparent cases have pneumonia
    • widespread consolidations or cavitations
      • mimics TB
• altered mental status
• jaundice
• diarrhea
• widespread metastatic abscesses
  • liver, spleen, parotid gland, prostate in male, cutaneous, subcutaneous, keratitis
• parotitis/parotid abscess common in children in Thailand
  • in endemic areas, melioidosis is the commonest cause of children's suppurative parotits
• hepatosplenic abscess common in Thailand
• prostatic abscess common in Australia

diagnosis

• Culture only
  • oxidase positive gram negative rods resistant to aminoglycosides but susceptible to co-amoxiclav should be assumed as B. pseudomallei until proven otherwise
• serological or molecular test have low sensitivity and low specificity
• unevenly stained gram negative bipolar bacilli

treatment

1. 2 weeks intensive parenteral antimicrobial

• ceftazidime or meropenem IV

1. 12-20 weeks eradicative oral antimicrobial

• co-trimoxazole or co-amoxicluv PO

prognosis

• mortality of severe mellioidosis 40% in Thailand, 14% in Australia
  • deaths within 48hrs after hospitalization common
  • less mortal without underlying condition
• treatment response slow
  • mean 9 days fever
• reinfection in 1-3.4% of survivors in long-term followup