A case report: Melioidosis
Jenma Rakkini1, Cecily Ruba2, Mahalakshmi3
1Nursing Supervisor, Kauvery Hospital, Cantonment
2Nurse Educator, Kauvery Hospital, Cantonment
3Nursing Superintendent, Kauvery Hospital, Cantonment
Abstract
The Gram-negative bacilli Burkholderia pseudomallei, which is found in contaminated water and soil and spreads via inhalation, inoculation, and ingestion, cause Melioidosis. Melioidosis manifests diversely in immunocompetent and immunocompromised patients, ranging from asymptomatic to life-threatening respiratory distress, septic shock, localized tissue infection, necrotizing pneumonia, and soft organ abscesses
Patients with diabetes mellitus are more prone to get melioidosis. The association of melioidosis with diabetes mellitus could be due to the defect in innate immunity of diabetic patients, along with poor glycemic control. Acute cases of melioidosis with diabetes mellitus showed decreased cellular adaptive immune response as compared to acute melioidosis cases in non-diabetic patients. Bone and joint involvement in melioidosis are rarely reported but are well-established entities. The knee joint is the most commonly affected, followed by the ankle, hip, and shoulder. The sternoclavicular joints can also be involved in the disseminated form of musculoskeletal melioidosis
Case Presentation
A 28 year aged male was admitted with C/o Cough and cold for 12 days
C/o Fever for 5 days
C/o Breathing difficulty for 3 days
Dyspnea on 14.07.2024 worsened on 15.07.2024
Initially treated elsewhere and came here for further management
Known case of Diabetes mellitus on treatment.
Social history
He is not habituated to cigarette smoking nor did he have alcohol addiction. He is not known to have any allergy.
Past medical history: He is a known case of Type 2 DM on irregular medications.
Past surgical history: No known surgical history.
Travel History: He has no travel history.
Occupation: Farmer
Physical Examination
Patient conscious, oriented
PR: 130/min
BP: 110/60mmHg
SpO2: 88% in 10litre of O2
CVS: S1S2 (+)
GCS 15
RS: B/L Crepts (+)
P/A: Soft
Initial Evaluation
- Echo screening on day of admission (POCUS) showed good LV dysfunction.
- Echo cardiogram on 19.07.2024:
- Global hypokinesia of LV
- Severe LV dysfunction
- Trivial MR
- Trivial T R
- Septae intact
- No pericardial effusion/clot
Multislice CT Scan Chest Plain Study (16.07.2024)
Extensive lobar consolidation involving the left lower lobe, lingular segment of left upper lobe and similar consolidation changes also in medial segment of right middle lobe and right lower lobe
Few centrilobular ground glass nodule in right upper lobe Likely infective etiology
Left mild pleural effusion
ECG: Normal
Blood culture and sensitivity (16.07.2024): Burkholderia pseudomallei
Tracheal secretion (16.07.2024): No growth in culture
Urine culture and sensitivity (16.07.2024): No growth in culture
Management
He had severe Diabetic Keto Acidosis and was started on IV insulin and fluids. Admitted in ICU
Consolidation, Right more than Left, with collapsed lung. A definitive airway was secured. Invasive line Started on appropriate antibiotics, IV fluids and other supportive medications. (Arterial line secured)
The patient’s metabolic acidosis improved but still had Hypoxia – ABG, SPO2 – 53. Gradually needed high Fio2, with ultrasound showing significant lung collapse and consolidation.
On inotropes with adequate urine output. Guarded prognosis explained. Kept patient on prone position continuously. Gradually requirement for inotropes decreased, and blood pressure was maintained. As SPO2 improved deproning was done.
On 21.07.2024 patient had desaturation despite the high FiO2 requirement, hence proning was resorted to given consolidation, with ARDS and high FiO2 requirement. Deproning was done on 23.07.2024 in view of improving FiO2 requirement.
He had developed severe LV dysfunction.
Post deproning he had FiO2 requirement which gradually worsened again needing proning. Proning was done for 2nd time. Following this patient’s FiO2 requirement improved to 65%. Hence he was deproned.
Gradually his shock worsened requiring high inotropic support. Also, his FiO2 requirement worsened again.
On 24.07.2024 by 08:00 AM, patient went for bradycardia and cardiac arrest.
In spite of adequate resuscitation patient could not be revived and was declared dead at 10:10 AM on 24.07.2024.
Specific Management Strategies for Melioidosis
Antimicrobial Therapy
Initial Therapy
- Ceftazidime: 2 g IV every 8 hours.
- Meropenem: 1 g IV every 8 hours.
- Imipenem: 500 mg IV every 6 hours.
These options are chosen for their efficacy against Burkholderia pseudomallei and are administered for a period of 10–14 days.
Transition to Oral Therapy
- Doxycycline: 100 mg orally twice daily.
- Trimethoprim-Sulfamethoxazole (TMP-SMX): 160 mg/800 mg orally twice daily.
The oral phase typically continues for 3–6 months, depending on the clinical response and disease severity.
Alternative Therapies
- Chloramphenicol or Azithromycin may be used if patients are intolerant to or resistant to the first-line agents.
Preventive Management of Melioidosis
1. Public Health Education and Awareness
Community Education: Inform communities in endemic areas about the risks of melioidosis and preventive measures. This includes information on recognizing symptoms, understanding the importance of early medical attention, and the nature of the disease
Risk Communication: Emphasize the need for vigilance during the rainy season or after heavy rainfall when the risk of soil and water contamination is higher.
2. Reducing Exposure to Contaminated Environments
Avoiding High-Risk Areas: Advise individuals to avoid contact with soil, mud, and stagnant water, especially in areas known to be contaminated with Burkholderia pseudomallei. This is particularly important after heavy rains or flooding.
Protective Clothing: Encourage the use of protective footwear, gloves, and long-sleeved clothing when working in or walking through potentially contaminated soil or water.
Proper Hygiene: Promote thorough handwashing with soap and water after potential exposure to soil or water. This is crucial for minimizing the risk of infection.
3. Safe Agricultural and Occupational Practices
Workplace Safety: Implement safety measures for agricultural workers, construction workers, and others who may come into contact with soil or water. This includes providing training on safe practices and the use of personal protective equipment (PPE).
Soil Treatment: In agricultural settings, consider soil treatments or practices that can reduce contamination with Burkholderia pseudomallei. However, the effectiveness of these measures may vary based on local conditions
4. Surveillance and Early Detection
Monitoring and Reporting: Establish systems for monitoring and reporting cases of melioidosis. Early detection of outbreaks can help implement targeted preventive measures and control the spread of the disease.
Health Screening: In endemic regions, consider health screening and surveillance for individuals who have frequent exposure to high-risk environments.
5. Environmental Management
Water Management: Ensure proper management and treatment of water sources to reduce the risk of contamination. This includes proper drainage and avoiding the accumulation of stagnant water.
Soil Management: Implement practices to reduce soil contamination and the risk of Burkholderia pseudomallei in areas where people live and work.
6. Vaccination and Research
Ongoing Research: Support research into potential vaccines and other preventive measures. While there is currently no vaccine available for melioidosis, ongoing research aims to address this gap
Vaccine Development: Encourage investment in the development of vaccines and other preventive strategies to reduce the incidence of melioidosis.
7. Travel Precautions
Travel Advisories: Provide travel advisories for individuals visiting endemic areas, including recommendations on avoiding high-risk environments and following protective measures.
Pre-Travel Information: Offer guidance to travelers on how to minimize their risk of infection, including recommendations for health precautions and seeking medical advice if symptoms develop.
Conclusion
Effective preventive management of melioidosis involves a multifaceted approach that includes community education, environmental controls, safe practices, and ongoing research. By implementing these strategies, the risk of infection can be significantly reduced, improving public health outcomes in endemic regions.
Ms. J. Jenma Rakkini
Nursing Supervisor
Ms. Cecily Ruba,
Nurse Educator
Ms. B. Mahalakshmi
Nursing Superintendent
