A 52-year-old painter presented to the outpatient department of a tertiary care teaching hospital with chief complaints of recurrent episodes of fever with chills throughout February 2021. He also complained of dull, aching, continuous, non-migratory pain in bilateral feet, the right knee, the right shoulder joint and the neck for the previous 20 days. This was accompanied by swelling of bilateral upper and lower limbs. The patient had a history of losing weight over the previous 4 years and uncontrolled diabetes mellitus for 8 years. He was also a heavy alcohol consumer (>5 drinks/day) and a chronic smoker. He was a resident of a rural district, Bhojpur, located in Bihar, East India, where he described himself as living in a kutcha house close to paddy fields. The patient belonged to a lower socioeconomic class corresponding to a score of 5 on a modified Kuppuswamy scale. There was no history of a similar disease in the past, or among the other family members. The patient also gave no history of trauma, tuberculosis or other respiratory complaints, prolonged antibiotic use, or surgery in the past.
On presentation, the patient had a temperature of 37  C, with a pulse rate of 78 beats min-1 and blood pressure of 98/72 mm of mercury. Examination revealed pallor and pitting oedema of the upper and lower limbs. On inspection, there was no erythema or discolouration of the skin over the limbs. Palpation of the knee and shoulder joint was acutely tender. The patient was unable to walk or abduct the right arm because of pain. Examination of other systems was unremarkable.
Random blood sugar on admission was 250 mg dl-1. Blood was collected for a complete haemogram, blood culture, renal function tests and viral serology. Haematological investigations revealed a total leukocyte count (TLC) of 17 000 microl-1, with 90.6 % neutrophils, and a platelet count of 38 000 microl-1. The patient had C-reactive protein (CRP) of 97.32 mg l-1 and glycosylated haemoglobin (HbA1C) of 13.53 %. Serum urea and creatinine were 53.5 and 0.98 mg dl-1, respectively, and the patient tested non-reactive for human immunodeficiency virus (HIV) and hepatitis B and C viruses. An ultrasound of the right lower limb revealed a 5.6 mm thrombus in the right saphenofemoral vein. A differential diagnosis of lower limb necrotizing fasciitis with deep vein thrombosis was made.
The patient was administered opioid analgesics to address excruciating joint pain. The antibiotics piperacillin/tazobactam, vancomycin and clindamycin were begun empirically for necrotizing fasciitis, in addition to insulin infusion and other supportive measures. However, within 48 h of admission, the patient became hypotensive and subsequently progressed to septic shock with acute kidney injury, requiring intensive care and inotropic support. Piperacillin/tazobactam was discontinued and the patient was started on meropenem 1 gm i.v. thrice daily.
Blood culture, collected soon after initial examination, flagged positive within 48 h of incubation. A Gram stain from the bottle showed bipolarly stained Gram-negative bacilli (Fig. 1). Within 48 h of incubation, growth on Blood and MacConkey agar showed medium-sized oxidase-positive colonies with dry margins and a metallic sheen. The organism was presumptively identified as   Burkholderia pseudomallei   by routine biochemical reactions and resistance to colistin, polymyxin B (300 units) and aminoglycosides, along with a sensitive zone size for amoxicillin/clavulanate. The identification was confirmed using the VITEK-II Compact system (bioMerieux, Marcy l'Etoile, France) with 98 % concordance. The isolate was uniformly susceptible to ceftazidime, meropenem, imipenem, doxycycline, and cotrimoxazole. The treating unit was promptly alerted about the organism. Antimicrobial therapy was revised by a multidisciplinary team consisting of physicians and microbiologists. The administration of injection meropenem (3 g/day) was continued, and injected vancomycin and clindamycin were stopped. Simultaneously, an urgent non-contrast computed tomography (CT) scan of the neck and thorax, and a contrast-enhanced CT of the abdomen, were planned to look for occult abscesses. Although the patient had no respiratory symptoms, radiological examination revealed multiple nodules in bilateral lungs with an abscess measuring 1.4x1.5x1.9 cm3 in the anterior segment of the right upper lobe, multiple soft tissue abscesses within muscles of the right shoulder joint, multiple prostatic abscesses and rim-enhancing splenic abscesses along with splenic vein thrombosis (Figs 2-4). Hence, the diagnosis was revised to disseminated septicaemic melioidosis with multiple deep organ abscesses and musculoskeletal involvement. The dose of injected meropenem was increased to 6 g/day, given the extent of the disease and the presence of deep organ abscesses. The patient showed gradual improvement over 1 week and was weaned off inotropes and intensive care. Urology and orthopaedic reference were sought for the prostatic abscesses, and possible septic arthritis of the knee joints, respectively. While a decision to allow spontaneous resolution of the prostatic abscess was taken, pig-tail drainage of the splenic abscess was considered. However, a day later, despite explaining the extent of the disease and the risk of fatality, the patient opted to be discharged. The patient was discharged on request following 14 days of intravenous meropenem. He was advised to continue treatment with intravenous meropenem for 4 more weeks, followed by an oral eradication therapy with cotrimoxazole for 3 months as recommended by the revised Darwin study consensus guidelines of 2020, and to maintain adequate glycaemic control. The patient was followed up telephonically a month after diagnosis. He had been compliant with intensive intravenous therapy and showed symptomatic improvement.
Computed tomography image (coronal view) showing a small lung abscess with air-fluid level (arrow) in the upper lobe of the right lung. Also, note the periarticular abscess around the right shoulder joint (arrowhead) that resulted from septic arthritis.