Case Presentation: A 74 year old, non-diabetic Singaporean male was hospitalized following 3 weeks of left iliac fossa pain. Computed tomography showed marked mural thickening and enhancement of descending and sigmoid colon with extensive pericolic and omental fat stranding. Ill-defined pulmonary nodules were also seen. He was treated for colitis but deteriorated with shock and abdominal guarding. Emergency laparotomy was performed and omentum was noted to be molted; small bowel appeared edematous and there was left-sided colitis with miliary abscesses in small bowel and colonic mesentery, reminiscent of gastrointestinal tuberculosis (TB). Unhealthy bowel was resected. Unexpectedly blood and mesenteric tissue cultures both grew Burkholderia pseudomallei; while endotracheal tube aspirates isolated Mycobacterium tuberculosis complex. TB cultures from bowel were negative. The patient was treated for melioidosis with 8 weeks of Ceftazidime and given Rifampicin-based TB treatment. He improved but unfortunately developed Steven Johnson’s Syndrome (SJS) to one of the drugs; and succumbed 4 months later from the complications of SJS.
Discussion: Burkholderia pseudomallei is a gram-negative bacterium, found in soil and muddy water in endemic areas such as northern Australia and Southeast Asia, which cause the disease melioidosis. Like TB, melioidosis is a versatile disease and a ‘great mimicker’ causing a wide range of symptoms. Major risk factors include diabetes, alcoholism, chronic renal disease and occupational exposure to soil e.g rice farmer. There are 4 main types of clinical manifestations: localised, pulmonary, bloodstream or disseminated. Localised disease can present with skin ulcers, nodules or abscesses. Pulmonary infection, with severity ranging from mild bronchitis to severe necrotising pneumonia, is most common. In bloodstream and disseminated disease, lesions can form in various solid organs and involve bones, joints, blood vessels, lymph nodes and skin. Mortality can be high, culture is the mainstay of diagnosis and treatment is with antibiotics for up to 6 months. Similar to TB, melioidosis can remain latent and reactivate. It was dubbed the ‘Vietnam time bomb’ following diagnosis in veterans who served in Vietnam years ago. Infection can occur via percutaneous inoculation, inhalation, and occasionally ingestion; and Burkhoderia pseudomallei is listed as a bioterrorism agent. Although epidemiologically similar, TB and melioidosis rarely occur concurrently. Our patient was unique in that he lacked risk factors, had melioidosis in an atypical site, co-infection with TB and unfortunate complication to treatment.
Conclusions: While uncommon in the United States, hospitalists should be aware of melioidosis; due to its latency, myriad of presentations; and threat for terrorism.