A 41-year-old male from Bangladesh presented to our hospital with complaints of dry cough, intermittent episodes of fever for the past 2 months, and weight loss of 17 kg over the previous 2 months. He was diabetic and had been on oral hypoglycemic agents and insulin for the past 1 year. He had no significant travel history to endemic regions.
On presentation to our hospital, he was febrile with stable vitals. On examination, he was found to have swelling around the right knee joint which was warm to touch and with restricted movements (120 ). Laboratory test results showed an elevated serum C-reactive protein level of 165 mg/dl, elevated erythrocyte sedimentation rate of 93 mm/h, and normal white blood cell count. The differential diagnoses considered were tuberculosis, infective endocarditis, and malignancy. Two-dimensional echo was normal with no evidence of any valvular vegetations. Chest X-ray showed patchy inhomogeneous opacities in both lower zones and trace left pleural effusion. He was put on empirical antibiotics, but continued having fever with increase in swelling of joints. CT chest was acquired, which revealed multiple patchy alveolar opacities in the bilateral upper and right middle lobes with adjacent ground glassing, mild bilateral pleural effusion, and few reactive mediastinal lymph nodes. Ultrasound of the knee showed effusion and the fluid was aspirated. Blood and joint aspiration fluid were sent for microbiological cultures both of which grew B. pseudomallei. Since the organism was known for its multifocal involvement, an F-18 FDG PET/CT was planned.
F-18 FDG PET/CT [Figure 1] revealed mildly FDG-avid fibrocavitatory changes in the apical segment of the right upper lobe (maximum standardized uptake value [SUVmax] 2.5) [Figure 2], non-FDG-avid nodules in the left lung, hypermetabolic subcarinal and left hilar lymph nodes [Figure 3], hypermetabolic hypodense lesion in segment VIII of the liver (size 1.0 cm x 1.2 cm SUVmax 2.6), hypermetabolic collection in the pericecal region (size 1.2 cm x 2.7 cm SUVmax 4.0) [Figure 4], effusion with FDG uptake in the right knee joint (SUVmax 4.7), and focal hypermetabolism noted in the left proximal tibia (SUVmax 3.4) [Figure 5].
He was started on ceftazidime 50 mg/kg Q6H for 3 weeks and levofloxacin 750 mg and cotrimoxazole 960 mg planned for 3 months.
On follow-up after 1 month, his symptoms had come down, he was afebrile, and he had gained weight.