A 47-year-old Indian male, presented with high-grade fever and left-sided pleuritic chest pain of 3-week duration. He complained of anorexia and significant weight loss of 6 kg in the last 1 month. There were no other respiratory symptoms, jaundice or bowel symptoms. The patient was diagnosed with diabetes and was on insulin therapy for the past 5 years. Two years ago, the patient was evaluated for hemoptysis, diagnosed as sputum-negative pulmonary TB on the basis of X-ray finding suggestive of right upper lobe fibrosis. He was treated with Isoniazid (H), Rifampicin (R), and Pyrazinamide (Z) for 2 months and with H, R and Z for 4 months. He was treated for small joint arthritis for 3 months prior to presentation. There was no history of recent exposure to pulmonary TB. There was no history of malignancies in the family. He is a reformed smoker and a chronic alcoholic. No history of recent travel to North Australia or Southeast Asia. There is no history of exposure to soil. There was no history of sexual promiscuity.
On examination his vitals were stable and he had a body mass index of 17.8 kg/m2. Abdominal examination revealed tenderness in the left hypochondrium and moderate hepatosplenomegaly. Per rectal examination did not reveal bleeding or deposits. On chest examination, there were fine crepitations and diminished air entry in the right upper chest. Examination of other systems was within normal limits.
His hemogram showed polymorphonuclear leukocytosis and an erythrocyte sedimentation rate of 70 mm/h. He had a fasting blood sugar value of 236 mg/dL and a postprandial value of 300 mg/dL with a urine sugar of 2%. His renal function and electrolytes were normal. His liver function tests and prothrombin time were within normal limits (WNL). His amylase and lipase levels were WNL. His chest X-ray showed right upper zone fibrosis. His upper and lower gastrointestinal endoscopies were normal. Ultrasonography of the abdomen showed a collection of heterogeneous echogenicity near the inferior pole of spleen suggestive of a perisplenic abscess. Contrast-enhanced CT scan of the abdomen revealed a splenic abscess with a breech in the capsule and extension of abscess into the perisplenic area (Fig. 1). His viral serology was negative for hepatitis B, C and human immunodeficiency virus.
The possibilities considered in this middle-aged gentleman presenting with fever, weight loss and arthritis with evidence of right upper lobe fibrosis, hepatosplenomegaly and perisplenic abscess were TB, brucellosis, melioidosis, lymphoma, salmonellosis and connective tissue disorders. His sputum was negative for acid-fast bacillus. Infectious screen was negative for enteric fever, malaria and brucella serology. He had positive rheumatoid factor and anti-cyclic citrullinated protein was negative. Anti-nuclear antibodies were absent and tumor markers were WNL. Trephine biopsy of the bone marrow was normal. The aspirate from the abscess revealed catalase- and oxidase-positive, gram-negative bacillus with bipolar staining and violet colonies with central umbonation in Ashdown's selective agar (Fig. 2), diagnostic of Burkholderia pseudomallei. Polymerase chain reaction for TB was negative in the aspirate. Blood, sputum and urine cultures were sterile.
The patient was diagnosed as melioidosis and treated with 2 weeks of parenteral ceftazidime (2 g t.i.d.) followed by oral co-trimoxazole (160/800 mg t.i.d.) for 12 weeks upon which he became symptom-free. His fever and arthritis subsided and follow-up ultrasound showed resolution of abscess. Chest X-ray showed improvement in the right upper lobe lesion. The response to the therapy confirmed our diagnosis of melioidosis.