A 3-Year-Old Boy With Fever and Drowsiness

Gavin Christian K.W. Koh, MB, BChir, MA, MRCP, DTM&H; Richard J. Maude, BSc, MBChB Hons, MRCP, DTM&H; Pramot Srisamang, MD

Disclosures

July 28, 2017

Discussion

The plain chest radiograph obtained on admission (Figure 1) showed diffuse bilateral infiltrates consistent with bilateral pneumonia.

Figure 1.

The patient was initially treated with broad-spectrum intravenous antibiotics, including ceftriaxone and metronidazole. Unfortunately, after 3 days of therapy, he continued to have spiking fevers, suggesting treatment failure. The patient was transferred to the pediatric service of the hospital, and empirical treatment with ceftazidime was initiated. On the basis of the geographic location of the case, the clinical history of aspiration of well water, and the nonresponse to standard antibiotic therapy for pneumonia, melioidosis was suspected.

During the rainy season, Burkholderia pseudomallei (formerly Pseudomonas pseudomallei) is commonly isolated in cases of community-acquired pneumonia in northeast Thailand and northern Australia.[1] It is an aerobic, motile, gram-negative, saprophytic bacterium commonly found in soil and surface water in southeast Asia and northern Australia. B pseudomallei infection is known as "melioidosis" (from the Greek words melis, which means "distemper of asses," and eidos, which means "the likeness of"). The disease is probably endemic to the geographic areas between latitudes 20°N and 20°S. Sporadic cases have been reported in Central and South America, the Caribbean, and eastern and western Africa.[2]

The clinical manifestations of melioidosis appear to be protean. Definitive diagnosis is made by identifying the causative organism from a clinical specimen. Given the lack of microbiological facilities in many parts of the tropics, the prevalence of melioidosis is almost certainly underestimated. In the United Kingdom, five cases of melioidosis were imported from Bangladesh between 1988 and 1998; however, Bangladesh only reported its first case in 1998.[3] Likewise, two cases of melioidosis imported from Honduras were reported in 2005 in the United States,[4] yet Honduras itself has never reported a case of melioidosis. In Thailand, the first case of melioidosis was reported in 1955, but the disease remained largely unrecognized until the availability of routine microbiological testing in the mid- to late 1970s.[5]

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