Melioidosis in Gujarat: a neglected tropical disease

Case report

A 67-year-old male from Munpur village, Mahisagar district, Gujarat was admitted as an emergency to our tertiary care centre in Surat. He had high-grade fever and worsening breathlessness for the previous two days. He was tachypnoeic, hypotensive (blood pressure = 90/60 mmHg) and hypoxic (SpO₂ 80% on room air). Oxygen supplementation was immediately commenced. An initial chest radiograph showed left lower lobe pneumonia and laboratory reports showed leucocytosis and elevated C-reactive protein, but normal liver and renal function tests. Our initial diagnosis was a community-acquired pneumonia, probably due to Streptococcus or Klebsiella pneumoniae. Treatment was started empirically with i.v cefoperazone-sulbactam (3 gm i.v. b.i.d) with oral clarithromycin (500 mg b.i.d.).

History obtained later revealed that the patient was a retired farmer and a chronic smoker, not diabetic, hypertensive nor alcoholic. He had an acute myocardial infarction in 2015 for which he underwent an angioplasty and, subsequently, coronary artery stenting. One month previously, he had a low-grade fever with cough and expectoration. He was treated locally but details were untraceable. His fever nonetheless resolved within a few days, but his cough persisted.

Following admission, his dyspnoea worsened and mechanical ventilatory support was required. A repeat chest radiograph after the first 24 h showed that a bilateral lower lobe pneumonia had developed. Blood culture and bronchoalveolar lavage fluid grew Burkholderia pseudomallei in culture as reported by VITEK 2 System, bioMérieux. His antibiotic regime was changed to meropenem (1 g i.v. t.i.d.) immediately. The isolate was sent to the Centre for Emerging and Tropical Diseases (https://www.melioidosisindia.com/) in Manipal, where B. pseudomallei was confirmed by specific monoclonal antibody-based latex agglutination and type three secretion system (T3SS1) gene polymerase chain reaction (PCR). Despite aggressive management, his hypoxia worsened and he died seven days later.

Discussion

Melioidosis is caused by inhalation, cutaneous inoculation or ingestion of the environmental saprophyte and CDC Tier 1 select agent B. pseudomallei. ¹ A recent modelling suggested that India, home to 1.3 billion people including 69 million diabetics, may have over 52,000 melioidosis cases per year. ² Despite the strikingly high estimate of the disease indicating the country as a ‘hot spot’, it remains elusive and underdiagnosed. A review of the published literature identified a total of 583 cases of melioidosis in India (during 1991–2018) with the majority from Karnataka and Tamil Nadu. ³ However, there was no report from Gujarat. Melioidosis has a wide range of clinical presentations and might be misdiagnosed as other endemic diseases such as tuberculosis, leptospirosis or brucellosis. ⁴ A basic diagnostic algorithm (Figure 1) is ideal for detecting it in the laboratory. OPEN IN VIEWER

Our case was challenging, since there were no recognised risk factors such as diabetes or chronic kidney disease. The only possible risk factor was occupational exposure to soil through farming. Although the disease did not present during the rainy season, a high index of suspicion and awareness by clinicians and microbiologists is mandatory.