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Melioidosis: a Potentially Life Threatening Infection

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Melioidosis: a Potentially Life Threatening Infection CONTINUING MEDICAL EDUCATION Melioidosis: A Potentially Life Threatening Infection SH How, MMed*, CK Liam, FRCP*· *Department of Internal Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, FO.Box 141, 27510, Kuantan, Pahang, Malaysia, **Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, MalaysIa Introduction example in Thailand, it is most commonly seen in the north-eastern region with an incidence of 4.4 per Melioidosis is caused by the gram-negative bacillus, 100,000 population per year'. In Northern Australia, Burkholderia pseudomallei, a common soil and fresh the incidence is higher (16.5 per 100,000 populations water saprophyte in tropical and subtropical regions. It 4 per yearY than that in Thailand • The incidence in is endemic in tropical Australial and in Southeast Asian Pahang and Singapore is 6.1 per 100, 000 population 23 4 countries, particularly Malaysia , Thailand and per year3 and 1.7 per 100,000 population per yearS, Singapores. However, only few doctors in these respectively. However, the true incidence may be endemic areas are fully aware of this infection. Hence, higher than that reported as most of these studies the management of this infection is often not included culture-confirmed cases only. Furthermore, appropriate and suboptimal. A recent study in Pahang some patients with mild infection from the rural areas has shown the incidence of this infection in Pahang3 is may not present to the hospital. More and more 4 comparable with that in northern Thailand • The melioidosis cases are being reported from previously overall mortality from this infection remains extremely unreported parts of the world especially southern high despite recent advancement in its treatment. In 6 8 9 lO China , Taiwan', India , Laos and Vietnam but the true the Pahang study, only 32% of patients were given an endemicity in these areas is not established. Also appropriate antibiotic empirically and about half of the isolated cases have been reported in the temperate culture-confirmed cases were not treated with countries among travellers returning from endemic appropriate intravenous antibiotic chemotherapy and ll areas -13 . most cases were not given eradication therapy. This review is to present to doctors working in endemic Melioidosis is a disease involving all age groups but areas about the diagnosis and proper management of commonly occurs in people between the ages of 40 to melioidosis. 60 years3 and is related to farming. It is less common in the paediatric age group. In the Australia study\ Epidemiology only 4% of patients were younger than 15 years The incidence of melioidosis varies between countries whereas in Malaysia, 7.60J01' and in Thailand, 10-17%15 of and also in different parts of the same country. For This article was accepted: 21 April 2006 . Corresponding Author: How Soon Hin, Kulliyah ofMedicine, International Islamic University, P. O. Box 747, Kuantan, Malaysia 386 Med J Malaysia Vol 61 No 3 August 2006 Melioidosis: A Potentially life Threatening Infection patients were in this age group. It is more common in with positive serology or whether treatment is males than females with the male to female ratio being necessary. 1.5:1 to 4.5:11-;. This may be due to more males being exposed in soil related occupations. Farming has been There are several classifications of the clinical shown to be strongly associated with incidences of manifestation of melioidosis. It may present as acute or 4 melioidosis • For instance in Thailand, 81% of chronic infection (defined as more than two months of melioidosis patients were rice-farmers and their family symptoms). The acute form of the disease commonly 4 members • Currently, the postulated mode of presents with septicaemia and is associated with very transmission is direct entry of the organism into the high mortality. On the other hand, the chronic form blood stream via very minor wounds or skin abrasions. commonly presents as long-standing suppurative focal Therefore, a definite history of injury is uncommon abscesses with fever and wasting and is associated with (5.2%)4. The second commonest mode of infection is a good prognosis". In endemic areas, 88-90% of cases 26 27 inhalation of contaminated dust. Strong wind increases present with the acute form of melioidosis ' • It can contaminated dusts in air resulting in an increased also be classified as localised or disseminated infection. number of melioidosis cases during the raining The latter is seen in 15-30% of cases"'. The widely season1,3,4. Other common modes of infection reported accepted classification is the presence or absence of are drowning" motor vehicle accident', via breast bacteraemia as this is an important predictor of the l6 17 milk , perinatal transmission and human-to-human ultimate outcome. The reported incidence of 1 transmission18. bacteraemia is 46-92% in most of the endemic areas .4. The highest incidence of bacteraemia of 92% reported Melioidosis occurs commonly (53-85%) in adults with in the literature is from Malaysia'. This is probably underlying diseases that predispose them to infection. related to late presentation as the patients normally In contrast, less than 20% of the paediatric patients seek traditional treatment before presenting to the have underlying diseases and almost all cases of hospitals. A higher frequency of diabetes mellitus in localised disease in this age gro\lP have no this study' may be another contributing factor as l4 predisposing factors ,1 5,19.20 In adults, diabetes mellitus individuals with diabetes are at higher risk for is the commonest underlying disease (20-74% of bacteraemic melioidosis". In Northern Thailand, 20% cases)!". Alcoholism and the consumption of kava (an of community acquired septicaemia is due to extract of the root of the plant consumed by the melioidosis and this infection contributes to 39% of the 29 Aboriginal people in Australia in place of alcohol) seem mortality due to septicaemia • to be a major factor associated with melioidosis in Australia. However, such habitual risk factors are less Fever is the commonest presentation and is present in common in Southeast Asia. Other underlying diseases almost all patients"'. The duration of fever may vary thought to be associated with melioidosis are chronic from a few days to months. Melioidosis is one of the renal failure, renal calculi, chronic lung disease causes of pyrexia of unknown origin in endemic areas. (especially cystic fibrosis in Australia), human Symptoms and signs depend on the site or organ immunodeficiency virus (HIV) infection, intravenous involved. Patients presenting with shock have a poor drug abuse, malignancy, systemic lupus erythematosus prognosis and have mortality in excess of 80% even in l and corticosteroid therapy. Table I summarises the a good centre . epidemiology and mortality of melioidosis in some of the endemic countries. White blood cell counts on admission commonly (55.6% of cases) show leucocytosis but may be normal Clinical Manifestation or low (3.7% of cases)'. Other evidence of sepsis such Asymptomatic seroconversion is common in endemic as thrombocytopenia, disseminated intravascular countries as evidenced by positive serology in up to coagulopathy, renal impairment, abnormal liver 50% of healthy adults in these countries"'23. As in the function, metabolic and respiratory acidosis are case of Mycobacterium tuberculosis, B. pseudomallei common presentations in severe infections. may remain dormant in macrophages for many years follOWing infection before causing disease when the Pulmonary Melioidosis host's immune system deteriorates. This is evident in Pneumonia is the commonest clinical manifestation and 1 American soldiers who developed melioidosis many is present in half of the cases .'. Patients may present 24 years after returning from Vietnam • Currently, there is with acute fulminant pneumonia with septicaemia no data on the outcome of these asymptomatic patients which commonly requires mechanical ventilation and Med J Malaysia Vol 61 No 3 August 2006 387 CONTINUING MEDICAL EDUCATION intensive care. This manifestation is associated with a intraabdominal lesions are empyema of the gall mortality exceeding 80%1. On the contrary, a more bladder, pancreatic abscess and adrenal abscessl.2. indolent presentation is associated with a better outcome". Cough is commonly productive of purulent Urogenital Tract Infection sputum and associated with fever. Haemoptysis is rare About 18% of adult males with melioidosis in Australia in acute disease but may be present in up to 31% of had prostatic abscess and the patients commonly patients with the chronic form of the disease",30. The presented with fever, abdominal pain, dysuria, diarrhoea chest radiograph in acute disease commonly shows and acute urinary retention requiring catheterisationl. either a localised patch or bilateral diffuse patchy However, prostatic abscess is not commonly seen in alveolar infiltration or multiple nodular lesions which Thailand and Malaysia probably due to underdiagnosis may coalesce, cavitate (cavities are usually thin-walled as not all melioidoisis patients undergo abdomen and and rarely contain air-fluid level) and form abscesses. pelvic CT scan examination. Digital rectal examination In the chronic form of the disease, the chest radiograph is useful to detect prostatic involvement but it cannot findings may be difficult to distinguish from that of differentiate between prostatic abscess and acute pulmonary tuberculosis
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