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A 42-Year-Old Farmer From Bangladesh With Respiratory Failure, Septic Arthritis, and Multiple Cavitating ConsolidationsFarmer With Respiratory Failure, Cavitations FREE TO VIEW

Mohammed H. AlShati, MD, FCCP; Rajinder M. Joshi, MD
Author and Funding Information

From the Division of Respirology and Sleep Medicine (Dr AlShati), Department of Internal Medicine and Department of Microbiology (Dr Joshi), Radiology, Nuclear Medicine and Laboratory Center, Yiaco Medical Co, Al-Adan Hospital, Ahmadi, Kuwait.

CORRESPONDENCE TO: Mohammed H. AlShati, MD, FCCP, Division of Respirology and Sleep Medicine, Al-Adan Hospital, PO Box 46969, Ahmadi, 64020, Kuwait; e-mail: dr_alshatti@hotmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(2):e56-e59. doi:10.1378/chest.13-3000
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Published online

A 42-year-old man was directly admitted to the ICU with respiratory failure and hypotension. Two weeks prior and just after returning from Bangladesh, he presented to a polyclinic with fever, right knee pain, and generalized aches, for which he received oral antibiotics. He was a farmer, had diabetes, never smoked, and consumed alcohol occasionally.

Figures in this Article
Physical Examination Findings

On arrival to the ICU, the patient was sedated, intubated, and placed on mechanical ventilation. He was febrile (temperature, 39.7°C), hypotensive (BP = 85/44 mm Hg), tachycardic (pulse, 124 beats/min), and hypoxemic, requiring 60% Fio2. Chest examination revealed diffuse crepitations. Fingernail clubbing was present, and the right knee was red and swollen with evidence of effusion. The rest of his examination was unremarkable.

Diagnostic Studies

Laboratory investigations showed a WBC count of 14,000/μL, a platelet count of 190,000/μL, and the following values: hemoglobin, 11.4 g/L; glucose,198 mg/dL; creatinine, 3.6 mg/dL; alanine aminotransferase, 780 U/L; aspartate aminotransferase, 560 U/L; alkaline phosphatase, 50 U/L; and normal bilirubin. The patient’s coagulation profile was unremarkable, and arterial blood gas measurements revealed a mixed respiratory and metabolic acidosis. His plain chest radiograph showed bilateral airspace disease with cavitations (Fig 1). Transthoracic echocardiography results were unremarkable.

Figure Jump LinkFigure 1  Plain posteroanterior chest radiograph showing multifocal cavitating consolidations. Endotracheal tube and right and left internal jugular central lines are also evident.Grahic Jump Location

The patient was empirically started on meropenem for suspected gram-negative sepsis and ARDS. Aspiration of the right knee joint recovered blood-stained pus. Direct microscopy and staining results for bacteria, including mycobacteria, and fungi were negative. Despite aggressive hemodynamic, pulmonary, and renal support, the patient failed to respond, and a chest CT scan was obtained a week later (Fig 2) that showed multiple cavitating consolidations. The abdomen and pelvis were radiologically normal. Except for a few gram-negative bacilli on Gram stain, a BAL specimen obtained via flexible bronchoscopy showed no acid-fast bacilli, Pneumocystis jirovecii or other fungal elements, parasitic forms, or evidence of alveolar hemorrhage. Serology for viral hepatitis, HIV, immunoglobulins, and antineutrophil cytoplasmic antibody was unremarkable.

Figure Jump LinkFigure 2  Axial CT scan with contrast (lung window) at different levels showing bilateral cavitation, consolidation, and effusion. A, Aortic arch. B, carina. C, T6 vertebrae. Patchy areas of ground-glass attenuation with interlobular septal thickening are also present.Grahic Jump Location

Bacterial cultures of synovial knee fluid, blood, and BAL specimens were all positive and exhibited the same type of growth. The colonies on blood agar were initially smooth but became dry and wrinkled on further incubation for the next 48 h. The organisms were actively motile, nonlactose fermenting, gram-negative bacilli with positive reactions for both catalase and oxidase. There was no growth under anaerobic and microaerophilic conditions. The strain grew very well at 42°C. Complete resistance to gentamicin and colistin was noted.

What is the diagnosis?
Diagnosis: Melioidosis with septic shock

Melioidosis is caused by the gram-negative bacterium Burkholderia pseudomallei. The organism is present in soil and fresh surface water, with peak incidence in wet seasons. It is endemic in Southeast Asia, especially Thailand, Northern Australia, and the Indian subcontinent. Sporadic cases have been described in other regions of the world; however, the disease is extremely rare without travel exposure.

Infection usually occurs following percutaneous inoculation, but may also occur due to inhalation of organism during tropical storms, aspiration with near drowning, and ingestion. Risk factors for melioidosis include diabetes, chronic lung or kidney disease, rheumatic heart disease, heavy alcohol consumption, immunosuppression, and malignancy. Occupational exposure to soil is also considered a risk factor, and melioidosis has a male preponderance. It is unclear whether the latter is related to higher occupational and recreational exposures in men or to genetic and hormonal factors.

The clinical picture is variable, ranging from subclinical infection to rapidly fatal disease. Pneumonia is the most common clinical manifestation of the disease, followed by localized skin infection. Septic arthritis as the presenting manifestation of the disease is uncommon. Bacteremia and septic shock are present in about one-half and one-quarter of patients, respectively, with a high mortality rate in the latter. Melioidosis can be confused with other infections, especially TB, as they share similar geographic distribution, clinical and radiologic manifestations, latent and active status, and multiorgan affection. Concurrent infection with both has also been reported. Common radiologic features of melioidosis include patchy consolidation, cavitation, nodules, effusion, and abscesses. The latter can also be found in the liver, spleen, prostate, or kidneys.

Definitive diagnosis of melioidosis can be established by culture of the organism from blood, body fluids, or tissues in the context of appropriate clinical picture, yet the diagnosis is often delayed. This is likely due to low index of suspicion or dismissing culture results as contaminants, especially in nonendemic areas, including North America. The organism is resistant to penicillin, ampicillin, aminoglycosides, colistin, and first- or second-generation cephalosporins.

Ceftazidime or carbapenems are the drugs of choice for severe infections and can be life saving if given early. Combination of these antibiotics with trimethoprim-sulfamethoxazole may be considered in areas with known resistance to these drugs. The optimum duration of therapy is unknown, yet therapy for 2 to 6 months is recommended based on the location and severity of infection. Granulocyte colony-stimulating factor has been shown to provide a favorable outcome in those with melioidosis and septic shock; however, there is no standard universal consensus for its use. Relapse is not uncommon and has been reported in about one-third of patients.

Clinical Course

Despite appropriate therapy and in vitro sensitivity, the patient’s clinical course deteriorated slowly. Repeated blood cultures grew the same organism, but it had become resistant to ceftazidime, tetracycline, and trimethoprim-sulfamethoxazole. His hemodynamics collapsed after 42 days of total ICU stay, and the patient died.

  • 1. Melioidosis is an infection caused by the gram-negative bacterium Burkholderia pseudomallei, which is present in soil and fresh surface water.

  • 2. Pneumonia and internal organ abscesses are the most common clinical manifestations.

  • 3. Culture is the main stay of diagnosis and early, often empirical therapy with ceftazidime or carbapenems is essential; yet mortality remains high in severe infections.

  • 4. A detailed travel history and high index of suspicion in those returning from Southeast Asia, especially Thailand, Northern Australia, or the Indian subcontinent, is important for early diagnosis and better management.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Struelens MJ, Mondol G, Bennish M, Dance DAB. Melioidosis in Bangladesh: a case report. Trans R Soc Trop Med Hyg. 1988;82(5):777-778. [CrossRef] [PubMed]
 
Turner MO, Lee VT, FitzGerald JM. Melioidosis in a diabetic sailor. Chest. 1994;106(3):952-954. [CrossRef] [PubMed]
 
Dance DAB, Smith MD, Aucken HM, Pitt TL. Imported melioidosis in England and Wales. Lancet. 1999;353(9148):208. [CrossRef] [PubMed]
 
Chan KP, Low JG, Raghuram J, Fook-Chong SM, Kurup A. Clinical characteristics and outcome of severe melioidosis requiring intensive care. Chest. 2005;128(5):3674-3678. [PubMed]
 
Rolim DB, Vilar DC, Sousa AQ, et al. Melioidosis, northeastern Brazil. Emerg Infect Dis. 2005;11(9):1458-1460. [CrossRef] [PubMed]
 
Thomas J, Jayachandran NV, Shenoy Chandrasekhara PK, Lakshmi V, Narsimulu G. Melioidosis—an unusual cause of septic arthritis. Clin Rheumatol. 2008;27(suppl 2):S59-61. [CrossRef] [PubMed]
 
Muttarak M, Peh WC, Euathrongchit J, et al. Spectrum of imaging findings in melioidosis. Br J Radiol. 2009;82(978):514-521. [CrossRef] [PubMed]
 
Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis. 2010;4(11):e900. [CrossRef] [PubMed]
 
Stewart T, Engelthaler DM, Blaney DD, et al. Epidemiology and investigation of melioidosis, Southern Arizona. Emerg Infect Dis. 2011;17(7):1286-1288. [CrossRef] [PubMed]
 
Ko SF, Kung CT, Lee YW, Ng SH, Huang CC, Lee CH. Imaging spectrum of thoracic melioidosis. J Thorac Imaging. 2013;28(3):W43-48. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1  Plain posteroanterior chest radiograph showing multifocal cavitating consolidations. Endotracheal tube and right and left internal jugular central lines are also evident.Grahic Jump Location
Figure Jump LinkFigure 2  Axial CT scan with contrast (lung window) at different levels showing bilateral cavitation, consolidation, and effusion. A, Aortic arch. B, carina. C, T6 vertebrae. Patchy areas of ground-glass attenuation with interlobular septal thickening are also present.Grahic Jump Location

Tables

Suggested Readings

Struelens MJ, Mondol G, Bennish M, Dance DAB. Melioidosis in Bangladesh: a case report. Trans R Soc Trop Med Hyg. 1988;82(5):777-778. [CrossRef] [PubMed]
 
Turner MO, Lee VT, FitzGerald JM. Melioidosis in a diabetic sailor. Chest. 1994;106(3):952-954. [CrossRef] [PubMed]
 
Dance DAB, Smith MD, Aucken HM, Pitt TL. Imported melioidosis in England and Wales. Lancet. 1999;353(9148):208. [CrossRef] [PubMed]
 
Chan KP, Low JG, Raghuram J, Fook-Chong SM, Kurup A. Clinical characteristics and outcome of severe melioidosis requiring intensive care. Chest. 2005;128(5):3674-3678. [PubMed]
 
Rolim DB, Vilar DC, Sousa AQ, et al. Melioidosis, northeastern Brazil. Emerg Infect Dis. 2005;11(9):1458-1460. [CrossRef] [PubMed]
 
Thomas J, Jayachandran NV, Shenoy Chandrasekhara PK, Lakshmi V, Narsimulu G. Melioidosis—an unusual cause of septic arthritis. Clin Rheumatol. 2008;27(suppl 2):S59-61. [CrossRef] [PubMed]
 
Muttarak M, Peh WC, Euathrongchit J, et al. Spectrum of imaging findings in melioidosis. Br J Radiol. 2009;82(978):514-521. [CrossRef] [PubMed]
 
Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis. 2010;4(11):e900. [CrossRef] [PubMed]
 
Stewart T, Engelthaler DM, Blaney DD, et al. Epidemiology and investigation of melioidosis, Southern Arizona. Emerg Infect Dis. 2011;17(7):1286-1288. [CrossRef] [PubMed]
 
Ko SF, Kung CT, Lee YW, Ng SH, Huang CC, Lee CH. Imaging spectrum of thoracic melioidosis. J Thorac Imaging. 2013;28(3):W43-48. [CrossRef] [PubMed]
 
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