A diabetic 64-year-old man presented with one month history of productive cough and poor appetite. There was no history of fever, hemoptysis or tuberculosis contact prior to admission.
On examination he was lethargic, icteric, tachypneic and dehydrated. He was afebrile but his blood pressure was low (100/60 mm Hg), he was tachycardic (152/min), and tachypneic with respiratory rate of 30/min. Bronchial breath sounds and coarse crepitation on left lower zone were heard. Spleen was slightly enlarged without any free fluid in the abdomen. No cardiovascular or neurological abnormality was noted. Chest radiograph showed right upper lobe cavity and surrounding consolidation. The initial working diagnosis on admission was pulmonary tuberculosis (TB) as we are in the endemic, high TB prevalent area. We also considered pulmonary aspergillosis and squamous cell carcinoma as differential diagnosis because of cavitary lung lesions in a diabetic patient.
Blood tests on admission showed a raised white cell count (22,590/uL) with predominant neutrophils (89%). Otherwise the hemoglobin and platelet levels were normal. Full blood picture revealed toxic granulation and left shift which were suggestive of infection. C reactive protein was markedly elevated (3.0 mg/L). His baseline coagulation profile on admission was within normal limits. There were also impairment of renal function with raised urea (144 mg/dl) and creatinine (2.71 mg/dl) and liver functions (AST 690 U/L, ALT 234 U/L, albumin 21 g/L, total bilirubin 3.51 mg/dl (direct 2.63 mg/dl). His diabetes was poorly controlled as reflected by HbA1c of 8.0%. The sputum cytology showed no malignant cells. Sputum AFB direct smear and TB PCR were both negative. Abdominal ultrasound revealed no evidence of intra-abdominal abscess.
He was started on high dose ceftazidime 1 g every 8 h in view of the underlying diabetes covering for pseudomonas infection in the lungs. On day 3 of admission, blood and sputum culture revealed Burkholderia pseudomallei which was sensitive to Ceftazidime. Hence, we increased the ceftazidime monotherapy dose to 2grams every 8 h for the treatment of melioidosis. He had persistent hypoxemia despite improving infective parameters hence CT pulmonary angiogram was carried out. CTPA showed right upper lobe cavitary lung lesion with necrotizing pneumonia and acute pulmonary embolism (PE) involving both descending pulmonary arteries (Fig. 1, Fig. 2).
He was started on IV heparin infusion with 6-hourly APTT monitoring.