A 33 year old, recently diagnosed diabetic male was admitted to our center with chief complaints of abdominal wall abscess located in left hypochondriac region since 1 month, high grade fever for 15 days and bilateral knee pain for 15 days along with loss of appetite and weight loss. He was chronic alcoholic for 18 years. The patient was undergoing treatment for the above complaints in some other hospital but was referred to our center after 12 days when his clinical condition didn't improve despite the ongoing treatment.
On admission, he was conscious, oriented, with heart rate of 78/min, BP - 130/88 mmHg, RR - 28/min and SpO2 99 % on room air and was therefore admitted to ward. His initial laboratory findings are shown in Table 1.
CECT abdomen was done which revealed multiple ill-defined hypotenuse lesion with peripheral and septal enhancement in right lobe of liver (largest 15 * 12 mm)? Abscess ? granuloma, splenic infarct at inferior pole and bilateral renal stone. Pus from base of ulcer was sent for culture and sensitivity and patient started on meropenem and metronidazole.
However, on day 3 patient's condition deteriorated. SpO2 dropped to 88 % and the sensorium was altered. He was immediately shifted to intensive care unit and was started on oxygen support via HFNC (FiO2-0.35, O2 flow-40 L/min.). ABG showed hypoxemic respiratory failure with pH of 7.498, pCO2 23.9 mmHg, pO2-58 mmHg HCO3-18.1 mmol/L.
HRCT chest was done which showed multiple tiny conglomerated nodules in B/l upper and middle lobes, B/L lower lobe consolidation, multiple subcentimetric, prevascular, pre and para tracheal and pre-carinal lymph nodes (Fig. 3). Repeat laboratory test was sent along with blood and urine culture and sensitivity. Bilateral knee joints were tense n tender, pus aspiration done and sent for culture and sensitivity.
Provisional diagnosis of melioidosis with MODS was made and patient upgraded to ceftazidime + avibactam, linezolid, doxycycline, trimethoprim and sulfamethoxazole.
Pus c/s from ulcer base, blood c/s and knee aspiration fluid showed growth of Burkholderia pseudomallei.
Patient's clinical condition was progressively improving, however, on day 8 he developed hypoxemic respiratory failure and was intubated in view of the same. Due to financial concern attendants took the patient leave against medical advice (LAMA) on day 10.
A 53 year male, known case of diabetes mellitus and hypertension, chronic alcoholic and smoker, presented in gastroenterology OPD with chief complaints of on and off low grade fever since 2 months associated with low appetite and weight loss. Before presenting to our center, the patient was undergoing treatment elsewhere for the above complaints where he was diagnosed to have multiple liver abscess. He came to our set up when his clinical condition didn't improve despite the ongoing treatment.
HRCT Thorax and CECT abdomen was performed which showed right lower lobe consolidation, multiple hypodense lesion in liver and spleen. FNAC from liver lesion showed acute inflammation suggestive of abscess. Patient was started on oral antibiotics on OPD basis, but subsequently patient lost the follow up.
He came back again to our center after 3 months. The patient was undergoing treatment at some other center where he was started on ATT. A repeat USG abdomen performed which showed increased in size and number of abscess both in liver and spleen. Initial lab investigations are shown in Table 1. The case was discussed with the Critical care Medicine (CCM) team on OPD basis, a strong suspicion of melioidosis was made and USG guided pus aspiration was done which was sent for culture sensitivity, tuberculosis and immuno-histochemistry.
The microbiological reports showed the growth of Burkholderia pseudomallei (Fig. 4) and was treated with inj. Ceftazidime for intensive phase. After the intensive phase, patient was started on eradication phase therapy (Tab Co-trimoxazole).