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6. Brown IH. The epidemiology and evolution lesions and milder clinical illness. The patient was treated with of infl uenza in pigs. Vet Microbiol. We describe an adolescent patient intravenous ceftazidime (150 mg/kg 2000;74:29–46. http://dx.doi.org/10.1016/ S0378-1135(00)00164-4 who had a benign, cutaneous form for 10 d), followed by oral cotri- 7. Ma W, Gramer M, Rossow K, Yoon KJ. of ; she had recently moxazole (800 mg of trimethoprim Isolation and genetic characterization returned to France from Guadeloupe, and 160 mg of sulfamethoxazole, of new reassortant H3N1 swine infl u- a Caribbean archipelago. 2×/d), with a total treatment duration enza from pigs in the midwestern . J Virol. 2006;80:5092–6. A 15-year-old girl without a of 12 weeks. Eleven weeks after http://dx.doi.org/10.1128/JVI.80.10.5092- medical history, except for asthma, treatment ended, the patient had 5096.2006 was evaluated in September 2010 for recovered, and the tumefaction of the 8. Vijaykrishna D, Poon LL, Zhu HC, Ma SK, muscle weakness, weight loss of 15%, arm had disappeared. Li OT, Cheung CL, et al. Reassortment of pandemic H1N1/2009 infl uenza A virus , and >40°C. During a trip The differential diagnosis for in swine. Science. 2010;328:1529. http:// to Guadeloupe 3 weeks before, she primary cutaneous melioidosis dx.doi.org/10.1126/science.1189132 had been infected by dengue virus, includes pyogenic , 9. Chen H, Wang Y, Liu W, Zhang J, Dong B, along with her brother and father, insect bites, mycobacterial and Fan X, et al. Serologic survey of pandemic (H1N1) 2009 virus, Guangxi Province, who recovered rapidly. Treatment other granulomatous lesions, and China. Emerg Infect Dis. 2009;15:1849– with and clavulanic acid adenopathies, but melioidosis is 50. was started after her return to France, usually not suspected in these despite the lack of a clear diagnosis, conditions, particularly in patients Address for correspondence: Qi Liu, Guangxi and induced a slight decrease in fever. from non–disease-endemic regions Center for Animal Disease Control and Clinical examination showed such as the Caribbean. Clinical Prevention, Nanning 530001, Guangxi, People’s a body mass index <15, multiple phenotypes of melioidosis range from Republic of China; email: [email protected] small adenopathies (<10 mm), asymptomatic carriage to fulminant small papulous skin eruptions, shock syndrome (1–5); death rates and an infl ammatory 15-mm–wide for the latter are ≈100% (3). Subacute tumefaction on the upper arm, melioidosis may be associated with evoking an adenopathy on ultrasound pulmonary and general signs; chronic investigation. Biological variants could give rise to abscesses 2 weeks later showed persistence of or septicemia in cases of concomitant Cutaneous infl ammation. Results of serologic immunodefi ciency (1–5), even tests for cytomegalovirus, Epstein-Barr decades after exposure. Signs and Melioidosis in virus, parvovirus B19, chikungunya symptoms of melioidosis can mimic Adolescent virus, Rickettsia, Coxiella, , those of tuberculosis, even though Returning from Brucella, and spp. did not there is no link between the infectious show acute infectious disease; results agents (2,4). Guadeloupe were positive for recent Cutaneous melioidosis may To the Editor: Melioidosis is an infection, despite absence of typical be primary (a single, nonspecifi c, emerging zoonosis caused by a highly . A 2-week sometimes ulcerated lesion, invasive and drug-resistant bacterium, treatment regimen with spiramycin measuring from several millimeters Burkholderia pseudomallei, that was started; general improvement to several centimeters) or secondary is found in soil and is endemic to followed, and the cough resolved. (multiple lesions associated with Southeast Asia and the Pacifi c region. The tumefaction of the upper arm visceral infection). In a study of 486 Few cases occur in other regions persisted, and a biopsy was performed. melioidosis patients in Australia, 58 (most imported by travelers) (1–5), Histologic results were nonspecifi c; (12%) had the primary cutaneous form but sporadic cases have originated culture on sheep’s blood Columbia (9). These cases were characterized by from the Caribbean (6–8). agar and chocolate agar produced younger patient age (more common Melioidosis can manifest small colonies of gram-negative among children <16 years of age), many years after exposure to B. bacilli after 24 hours’ incubation at higher frequency during the dry 35°C in an atmosphere of 5% CO . season, better prognosis in spite of pseudomallei and can cause severe, 2 systemic infection, including multiple This bacillus was later identifi ed as a possible chronic evolution, and abscesses of internal organs and skin. B. pseudomallei by using the Vitek2 absence of classic risk factors (9) such A less severe manifestation, primary test card (bioMérieux, Marcy l’Etoile, as diabetes, alcoholism, chronic renal cutaneous melioidosis, causes skin France). Identifi cation was confi rmed or pulmonary infections, surgery, by sequencing of 16S rRNA. , or cystic fi brosis (1–5).

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 2, February 2012 359 LETTERS

The case we describe is consistent Roderich Meckenstock, Address for correspondence: Roderick with the cutaneous variant of Audrey Therby, Meckenstock, Department of Internal melioidosis. However, the patient’s Stephanie Marque-Juillet, Medicine and Infectious Diseases, Versailles initial general symptoms (probably Sebastian Monnier, David Khau, Hospital, 78150 Le Chesney, France; email: attenuated by early treatment with Beatrice Pangon, [email protected] antimicrobial drugs) could have and Alix Greder-Belan indicated a transitory, disseminated Author affi liation: Versailles Hospital, Le phase of disease such as that Chesnay, France experienced by 4 (all adults) of the 58 DOI: http://dx.doi.org/10.3201/eid1802111603 cases of primary cutaneous melioidosis in the Australian study (9). It is not References known whether B. pseudomallei Geographic was transmitted to the patient by an 1. White NJ. Melioidosis. Lancet. 2003;361: airborne route or percutaneously as 1715–22. http://dx.doi.org/10.1016/S0140- Distribution of in most cases (i.e., wounds infected 6736(03)13374-0 2. Currie BJ. Melioidosis: an important Endemic Fungal by contaminated water or mud); other cause of in residents of and Infections among modes are anecdotal travellers returned from endemic regions. (1–5). Moreover, our patient had none Eur Respir J. 2003;22:542–50. http:// Older Persons, of the classic risk factors, although dx.doi.org/10.1183/09031936.03.000062 03 United States dengue fever as an underlying co- 3. Cheng AC, Currie B. Melioidosis: epidemi- infection has been described (10). ology, pathophysiology and management. To the Editor: We read with The patient was treated with Clin Microbiol Rev. 2005;18:383–416. interest the article by Baddley intravenous ceftazidime and oral http://dx.doi.org/10.1128/CMR.18.2.383- et al. (1) and appreciate their 416.2005 cotrimoxazole at the minimum 4. Valade E, Thibault FM, Biot FV, Vidal efforts to characterize incidence treatment duration recommended for DR. Melioidosis: an emerging tropical rates of mycoses. We agree that melioidosis (1–5). Purely cutaneous disease. Med Trop (Mars). 2009;69:437– histoplasmosis, blastomycosis, and variants of melioidosis may be treated 45. coccidioidomycosis are differential 5. Keluangkhot V, Pethsouvanh R, Stro- exclusively by oral cotrimoxazole bel M. Mélioïdose. Med Mal In- diagnoses for patients with consistent over 12 weeks (9), but we opted fect. 2005;35:469–75. http://dx.doi. symptoms but who reside outside to prescribe initial intravenous org/10.1016/j.medmal.2005.08.001 mycosis-endemic areas. treatment because of her general 6. Pérez JM, Petiot A, Adjide C, Gerry F, However, we believe that the Gourdsaud R, Juminer B. First case re- symptoms. We stopped follow-up port of melioidosis in Guadeloupe, a methods of Baddley et al. probably 11 weeks after the treatment period French West Indies archepelago. Clin do not determine the true incidence of ended because of persisting illness Infect Dis. 1997;25:164–5. http://dx.doi. these mycoses in sparsely populated remission, but lifelong monitoring is org/10.1086/516896 states such as Arkansas. Their estimates 7. Gétaz L, Abbas M, Loutan L, Schrenzel J, recommended for adult patients (1,4) Iten A, Simon F, et al. Fatal acute meli- contrast markedly with surveillance because relapses occur in ≈10% of oidosis in a tourist returning from Marti- data from the Arkansas Department adult patients despite well-conducted nique Island, November 2010. Euro Sur- of Health (Table) and with our clinical antimicrobial drug treatment (3,4). veill. 2011;16:pii:19758. experience as infectious disease 8. Hurtrel G, Hurtrel G, Olive C, Vignier N, In conclusion, melioidosis as a Viron F, Rosine J, et al. La mélioïdose en physicians. We characterize Arkansas potential emerging infectious disease Martinique: à propos de trois cas simul- as a state in which histoplasmosis and should be considered in cases of tanés. Presented at 12th Journées Nation- blastomycosis incidence is high and isolated skin lesions as well as in cases ales d’Infectiologie; 2001 Jun 8–10; Tou- coccidioidomycosis incidence is low; louse, France. Abstract L-05. of unexplained fever with nonspecifi c 9. Gibney KB, Cheng AC, Currie BJ. Cu- however, Baddley et al. indicate that in symptoms. Furthermore, the disease taneous melioidosis in the tropical top Arkansas, incidence of blastomycosis should be considered not only among end of Australia: a prospective study is relatively low and incidence of travelers returning from known and review of the literature. Clin In- coccidioidomycosis is high. fect Dis. 2008;47:603–9. http://dx.doi. disease-endemic regions but also in org/10.1086/590931 To investigate whether this those coming from the Caribbean. 10. Pongrithsukda V, Simakachorn N, Pimda fi nding might be associated with J. Childhood melioidosis in northeastern their small 5% sample of Medicare Thailand. Southeast Asian J Trop Med benefi ciaries, we used data from the Public Health. 1988;19:309–16. Arkansas census to determine that in 2008 the population of adults

360 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 2, February 2012