Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 48, Num. 2, 2002, pp. 124-126

Journal of Postgraduate Medicine, Vol. 48, Issue 2, 2002 pp. 124-126

Burkholderia pseudomallei: Abscess in an Unusual Site

Kiertiburanabul S, Sungkanuparph S, Kositchiwat S, Vorachit M

Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Rama 6 Rd., Bangkok 10400, Thailand.
Address for Correspondence: Sasisopin Kiertiburanabul, MD, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Rama 6 Rd., Bangkok 10400, Thailand. E-mail: sasisopin@hotmail.com

Code Number: jp02040

Abstract:

Melioidosis is an infection caused by Burkholderia pseudomallei. It is an important human pathogen in tropical area. The clinical manifestations are protean and multisystem involvement. We report an unusual case of melioidosis with abscess at root of mesentery in an elderly, non-insulin dependent diabetes Thai women. She presented with prolonged fever and chronic abdominal pain. The early clinical diagnosis was carcinomatous mass with peritonitis. Diagnosis of melioidosis arose from the surgical finding and pus culture. Treatment with surgical drainage and ceftazidime followed by co-trimoxazole plus doxycycline had a good clinical outcome.

Key Words: Melioidosis, Burkholderia pseudomallei, abscess, root of mesentery.

Melioidosis is an infection caused by Burkholderia pseudomallei (B. pseudomallei). It is endemic in southeast Asia and northern Australia.¹ The organism is found in soil and surface water. More than half of the patients have underlying predisposing conditions, such as diabetes and renal disease.² Clinically, the disease ranges from unsuspected asymptomatic infection to overwhelming and fatal septicaemia. Infection has been reported in all age groups. Many studies on melioidosis have been published, however, there are limited studies that have described melioidosis with abscess in unusual sites apart from liver and splenic abscess. We report a case of melioidosis with abscess at root of mesentery.

Case History

A 70-year old non-insulin-dependent diabetic Thai woman who lives in the east of Thailand presented with a history of intermittent and low grade fever, progressive left-lower-quadrant abdominal pain, anorexia, weight loss of six kg and bowel habit change for a month. Abdominal examination revealed marked tenderness and rebound tenderness at the left lower quadrant with generalized guarding. No abnormal mass could be detected and bowel sounds were normal. Haematological and biochemical indices, apart from a haematocrit of 33.9%, alkaline phosphatase and gamma-glutamyltransferase of 226 U/L (50-136) and 189 U/L (7-55) respectively, were within normal range. Computerised tomography (CT) of the abdomen showed the well-defined border soft tissue mass 5x9x8 cm in diameter at root of mesentery (Figure). A carcinomatous mass with peritonitis was initially suspected and an exploratory laparotomy was performed, 100 ml of yellow turbid peritoneal fluid and multiloculated abscess with 50 ml of pus at root of mesentery were found. Drainage of the abscess and appendectomy were done. The patho-logical diagnosis of soft tissue and veriform appendix was granulomatous inflamm-ation and lymphoid hyperplasia with chronic peri-appendicitis, respectively. The patient was initially given four drug anti-tuberculosis treatment on the second day after the operation. The pus from the root of mesentery was cultured aerobically on blood and MacConkey agar. Two days after incubation, scanty growths of gram-negative non-lactose fermenter colonies were isolated. The organism appeared as gram-negative bipolar staining bacilli. On triple sugar iron agar, it produced acid slant, neutral butt without hydrogen sulfide. It produced catalase, oxidase, lipase, and gelatinase enzyme, reduced nitrate to nitrogen gas and used citrate as the source of carbon. It also oxidized arabinose, dextrose, inosital, lactose, maltose, mannitol, sucrose, sorbitol, trehalose and xylose. It yielded negative results for indole, lecithinase, methyl red and Voges-Proskauer test. The organism was identified as B. pseudomallei. The complete result was reported on the seventh day after the operation. Two samples of blood culture were negative after seven days. Serology for B. pseudomallei (agglutination assay) was performed after the microbiological result, showed a titer of 1:40. The medical treatment was switched to ceftazidime (2 g q 8h) for two weeks, following by oral maintenance treatment with co-trimoxazole plus doxycycline for 20 weeks. The patient's clinical condition improved and the radiological evolution of abdomen became normal before the treatment was discontinued. She had no recrudescence of melioidosis during a year follow-up period.

Discussion

In Thailand, the endemic area of melioidosis is in the northeast where septicaemic melioidosis accounts for approximately one-fifth of all community-acquired septicemias.³ The infection is thought to result from inoculation, ingestion, or inhalation of the environment organisms. The incubation period is unknown.⁴ Most of the patients had underlying predisposing conditions, such as diabetes millitus² and this is present in our patient. The clinical manifestations of melioidosis are ranging from chronic abscess formation to fulminant sepsis. The patient can be classified into four clinical groups; disseminated septicaemic melioidosis is defined as positive blood culture and more than one organ involved, non-disseminated septicaemic melioidosis is defined as positive blood culture and only one foci or no apparent focus of infection, localised melioidosis is defined as only single focus of infection whereas negative blood culture and multifocal localised is defined as multiple organs involvement but negative blood culture.^5,6 Septicemia is the most common presentation.¹ Many reports of melioidosis with abscess in unusual sites such as central nervous system, parotid gland, neck area, adrenal gland, and prostate gland^4,6,11 had published but there is no report of case with abscess at root of mesentery. The abscess in this patient was initially suspected as carcinomatous mass because of the unusual site.

The pathological diagnosis of the tissue also simulated tuberculosis. The patients with chronic melioidosis, the lesion may show as granulomatous and usually confined to a single organ and bacteria are rarely demonstrable in tissue section.¹² Diagnostic confusion with tuberculosis can occur, especially in the area with a high incidence of both diseases, such as in Thailand. The diagnosis of melioidosis in this patient arose

from the recovery of the organism in pus culture. Melioid antibody titre in this patient was low and might not be helpful since the titer to be considered positive is 1:160 for the patients in endemic area. Serologic methods for diagnosis are unreliable: the IHA is not consistently raised in cultured-positive melioidosis. The optimal antimicrobial treatment for melioidosis is uncertain and duration of therapy is unknown. Surgical drainage and ceftazidime monotherapy followed by long-term maintenance treatment with co-trimoxazole plus doxycycline results in a good clinical outcome. This patient is likely to have low risk of relapse because she had a localized disease and ceftazidime was given during the acute phase.⁵

This case report demonstrates an unusual site of melioidosis, root of mesentery, and it should be considered as a possibility when abscess are encountered at an unusual sites in patients who are in endemic areas and have predisposing conditions. Thus, culture for B. pseudomallei should be performed in patients presents with clinical syndromes compatible with melioidosis and the pathological diagnosis of the tissue revealing granulomatous process. With appropriate surgical and medical therapy; the prognosis of this condition is good, which contrasts with the high mortality rate seen in septicaemic form.

References

1. Leelarasamee A, Bovornkitti S. Melioidosis: review and update. Rev Infect Dis 1989;11:413-25.
2. Lumbiganon P, Tattawasatra U, Chetchotisakd P, Wongratanacheewin S, Thinkhamrop B. Comparison between the antimicrobial susceptibility of Burkholderia pseudomallei to trimethoprim-sulfamethoxazole by standard disk diffusion method and by minimal inhibitory concentration determination. J Med Assoc Thai 2000;83: 856-60.
3. Chaowagul W, White NJ, Dance DA, Wattanagoon Y, Naigowit P, Davis TM, et al. Melioidosis: a major cause of community-acquired septicemia in northeastern Thailand. J Infect Dis 1989;159:890-9.
4. Karcher AM, Zaman A, Brewis C, Fahmy T. Neck lumps: expect the unexpected. Lancet 2000;355:1070.
5. Chaowagul W, Suputtamongkol Y, Dance DA, Rajchanuvong A, Pattara-arechachai J, White NJ. Relapse in melioidosis: incidence and risk factors. J Infect Dis 1993;168:1181-5.
6. Dhiensiri T, Eua-Ananta Y. Visceral abscess in melioidosis. J Med Assoc Thai 1995;78:225-31.
7. Lath R, Rajshekhar V, George V. Brain abscess as the presenting feature of melioidosis. Br J Neurosurg 1998;12:170-2.
8. Peetermans WE, Van Wijngaerden E, Van Eldere J, Verhaegen J. Melioidosis brain and lung abscess after travel to Sri Lanka. Clin Infect Dis 1999;28:921-2.
9. Dance DA, Davis TM, Wattanagoon Y, Chaowagul W, Saiphan P, Looareesuwan S, et al. Acute suppurative parotitis caused by Pseudomonas pseudomallei in children. J Infect Dis 1989;159:654-60.
10. Mathew S, Perakath B, Mathew G, Sitaram V, Nair A, Lalitha MK, et al. Surgical presentation of melioidosis in India. Natl Med J India 1999;12:59-61.
11. Lee SC, Ling TS, Chen JC, Huang BY, Sheih WB. Melioidosis with adrenal gland abscess. Am J Trop Med Hyg 1999;61:34-6.
12. Piggott JA, Hochholzer L. Human Melioidosis: A histopathologic study of acute and chronic melioidosis. Arch Path 1970;90:101-11.

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