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Melioidosis Poster.Cdr EmergenceEmergence ofof MelioidosisMelioidosis inin IndonesiaIndonesia Ÿ Melioidosis is a community-acquired infectious disease caused by Burkholderia 1,2Patricia M. Tauran 1Department of Clinical Pathology, Faculty of Medicine, Hasanuddin 1 University/Dr. Wahidin Sudirohusodo Hospital, South Sulawesi, Indonesia pseudomallei which lacks a specific clinical presentation. 2 Nurhayana Sennang Indonesia Research Partnership of Infectious Disease, Jakarta, Indonesia 1 Ÿ The current diagnostic gold standard for B. pseudomallei is culture but it can be Benny Rusli 3Center of Tropical Medicine and Travel Medicine, Division of Infectious 1 3 Diseases, Department of Medicine, Academic Medical Center, University of N misidentified as a culture contaminant or as another species. W. Joost Wiersinga O 4,5 Amsterdam, Amsterdam, The Netherlands I Ÿ David Dance 4 T The crude case fatality rate ranges from 14% to 40%, and could be as high as 80% if Lao-Oxford-Mahosot Hospital–Wellcome Trust Research Unit, Vientiane, Lao 2 1 C effective antimicrobial drugs are not given. Mansyur Arif People’s Democratic Republic 5 U 6,7 Ÿ Direk Limmathurotsakul Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, D Melioidosis is known to be highly endemic in parts of southeast Asia and northern United Kingdom O 3 6 R Australia. Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol T N I Ÿ University, Bangkok, Thailand Both human and animal melioidosis cases exported from Indonesia have been 7 4-8 Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, frequently observed in many countries. Mahidol University, Bangkok, Thailand Ÿ Here, we report three cases of culture-confirmed melioidosis presenting at Wahidin Hospital, South Sulawesi, Indonesia, between 2013 and 2014. TABLE 1. Reported indigenous human cases of melioidosis in Indonesia Year Locations Age/ Gender, Clinical characteristics Diagnostic method (bacterial Outcome presented(ref) Nationality identification method) Ÿ The gold standard for diagnosis is Culture; organism commonly misidentified as 19299 Cikande, 50/M,Indonesian Chronic painless nodules in the left thigh with Culture of pus (biochemistry, phenotypic Died contamination or Pseudomonas spp. Java fistula discharging greenish yellow pus and virulence in animal model)) 193410 Jakarta, 38/M,Indonesian Severe sepsis with pulmonary, splenic and Culture of pus (biochemistry, phenotypic Died Ÿ Clinical sample : Blood, respiratory secretion, urine, pus and fluid Java prostatic abscesses (postmortem) and virulence in animal model) Ÿ 11 S Laboratory diagnosis of melioidosis: 1935 Surabaya, 25/F,Indonesian Abscess in the right gluteal region Culture of pus (biochemistry, phenotypic Fully recovered D Ÿ Gram-negative bacillus, oxidase positive Java and virulence in animal model) O Ÿ 193612 Bogor, Java 60/M,Indonesian Skin lesion with ulcers on right lower leg after Culture of pus (biochemistry and Fully recovered H Dry and wrinkle colonies and sweetish earthy odor trauma phenotypic) T Ÿ Resistance to gentamicin and colistin and susceptibility to co-amoxiclav is 12 E 1937 Jakarta, 55/M,Indonesian Abscess left foot, originated from small Culture of pus (biochemistry and Fully recovered M characteristic Java trauma while farming phenotypic) 195013 Surabaya, 28/F,European Pain in the lower abdomen and then high Culture of abscess from the right ovary Fully recovered Sample Microscopy Inoculation Macroscopy Identification Antibiotic susceptibility Java fever (biochemistry and phenotypic) Blood, testing 14 Resistance to 2005 Banda Aceh, 15/F;18 Pneumonia Culture of sputum (API20NE) Fully recovered respiratory Non-selective media: Sumatra mo/M;10/F;13/F (n=1) or reported vitek gentamicin and secretion, blood agar & colistin and (4 tsunami as improving urine, pus and MacConkey agar blood mac ashdown susceptibility to survivors) (n=3) fluid Selective media: agar conkey agar coamoxiclav is agar characteristic API 20NE 2011-201315 Malang, 51 Patients Unknown Culture of sputum, blood, pus and urine Unknown Java (VITEK2) 2013(Case 1) Luwu Timur, 41/M,Indonesian High grade fever, chill, headache and Culture of blood (VITEK2) Died Sulawesi shortness of breath Age 41 years old 2013(Case 2) Makassar, 45/F,Indonesian Skin ulcer on neck, fever, vomiting, Culture of blood (VITEK2) Died Sex Male Sulawesi abdominal pain, headache, diarrhea, poor appetite and weight loss Occupation An excavator operator in Tambak Yoso village, Kalaena District, East Luwu Regency. History He was referred from I La Galigo Five days of fever, chill, shortness of No underlying diseases 2014(Case 3) Makassar, 26/M,Indonesian Purulent discharge from incised wound Culture of Pus (VITEK2) Lost to follow-up Hospital, East Luwu Regency to Wahidin breath, headache and confusion Sulawesi behind the left ear lobe, painless and no fever Hospital in August 2013 E On Admission (day-1) Physical examination : fever (39.8°C), icteric sclera, hepatomegaly, abdominal tenderness, and calf tenderness S Ÿ A Laboratory test: Leukopenia (2,700/μL), thrombocytopenia (37,000/μL), hyperglycemia (350 mg/dL), hyperbilirubinemia (total This is the first report of indigenous melioidosis cases in Sulawesi. C 1 bilirubin 4.4 mg/dL and direct bilirubin 3.9 mg/dL) and hypercreatinemia (4.5 mg/dL). 1. Clinical manifestations are consistent with common clinical presentations of melioidosis: Rapid diagnostic tests for leptospirosis, dengue infection, and malaria : negative. 1.a.Case 1 and 2 : severe sepsis with multiple organ failure Presumptive diagnosis Weil’s disease and type 2 diabetes mellitus Therapy intravenous ceftriaxone and subcutaneous insulin 1.b.Case 3 : localized subcutaneous abscesses that fail to improve after treatment with He died because of septic shock (day 2) antimicrobials ineffective against B. pseudomallei. Blood culture B. pseudomallei (day 5) 2. Identification B. pseudomallei by VITEK2 is generally reliable1, although no further confirmatory tests1 because the isolates were not stored. Ÿ Previous reports of indigenous melioidosis from Indonesia were from Sumatra and Java. Age 45 years old Sex Female Ÿ Considering that melioidosis is endemic in east Malaysia and Papua New Guinea, it is likely Occupation A housewife in Makassar that indigenous melioidosis cases also occur unrecognized and unreported in the contiguous 3 History She was referred Three months of During the past Fever, abdominal Diabetes mellitus and parts of Indonesia, Kalimantan and Papua, respectively. from Daya swelling on the right month : the mass pain, vomiting, hypertension for 3 Regional Hospital, side of the neck became bigger, diarrhea, poor years. Makassar to ruptured, and appetite, and lost 5 Ÿ Our findings strongly support the suggestion that melioidosis is endemic throughout Indonesia Wahidin Hospital in produced kgs 3 thick, white pus. but is currently under-recognized. E On Admission (day-1) Physical examination : febrile (38.1°C), discharge of pus from neck abscess S Ÿ Burkholderia pseudomallei isolates from all the three cases were identified by VITEK2 Compact A Laboratory test: Hyperglycemia (310 mg/dL). Sputum acid-fast bacilli smears were negative C 2 N Complete blood count, renal and function tests, and liver function tests were normal (installed at Wahidin Hospital in December 2012). IO Chest radiography : cardiomegaly with pulmonary edema and signs of pulmonary hypertension S Ÿ Before 2012, B. pseudomallei was likely misidentified or discarded as a contaminant.1 Diagnosis Suspected tuberculous lymphadenitis and type 2 diabetes mellitus S U Therapy intravenous ceftriaxone, subcutaneous insulin, and oral meloxicam and metronidazole C Ÿ Guidance on how to diagnose melioidosis and identify B. pseudomallei, even without the use of S Day 4 dyspnea I 1 D automated machines such as VITEK, was recently published. Cardiologist diagnosis Chronic heart failure due to coronary artery disease She died due to cardiogenic shock (day 6) Ÿ None of the isolates were tested for antimicrobial susceptibility because this was not included in Pus culture B. pseudomallei (day 7) the laboratory’s standard operating procedures (SOPs) for this organism. Ÿ Burkholderia pseudomallei can also cause laboratory-acquired infection, and appropriate safety 1 Age 26 years old precautions for suspected isolates is required. Sex Male Occupation An employee of a state-owned enterprise Ÿ Since the recognition of these three cases, laboratory SOPs for bacterial identification and susceptibility testing and reporting are being revised in the hospital. History He was presented at Ear Nose Ten days of an abscess (marble- No underlying diseases. Throat (ENT) Clinic, Wahidin sized lump) behind his left ear that Hospital, Makassar, in February was not improve despite treatment Ÿ None of the three patients reported received antimicrobials recommended for melioidosis2 2014 (incised, drained and unknown medication) at a private hospital. because of the delayed recognition of the organism. ENT clinic (day 1) E Ÿ Treatment guidelines for clinicians in the Wahidin hospital are being revised to consider S Physical examination: Afebrile (36.6°C) A empirical treatment with antimicrobials effective against B. pseudomallei in patients presenting 1,2 C 3 Hearing was normal and tympanic membrane was intact. The incised wound was painless with severe sepsis and hyperglycemia. Theraphy: Oral ciprofloxacin and wound dressing ENT clinic (day 8) Complaining of persistent discharge Further incision and drainage was performed and the pus
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