Published Date: 2009-10-24 13:00:10
Subject: PRO/AH/EDR> Melioidosis - Spain ex Gambia
Archive Number: 20091024.3662
MELIOIDOSIS - SPAIN ex GAMBIA
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
Date: Fri 23 Oct 2009
From: Dr. Juan Antonio Cuadros Gonzalez [edited]
_Burkholderia pseudomallei_ infections are well known and endemic in
South East Asia, India and Australia, however, there have been also
increasing reports of confirmed locally acquired cases and small
outbreaks in the Americas (especially Brazil) and some African
countries. Infections by this bacterium have been related to climatic
phenomena as the 2004 tsunami in Indonesia, and some experts also
suggest that the climatic change could modify the distribution and
prevalence of this disease.
We report here what seems to be the 1st case of imported melioidosis
in Spain. This case illustrates once more as clinical physicians and
microbiology laboratories must work now in a real global perspective.
A young male diabetic immigrant from Gambia living in Spain since
years, presented in the emergency room with fever, bilateral
intramuscular abscess in the calf, cough and hemoptysis. He had
travelled to southern Gambia (Sambaya) from May to October 2009. He
was diagnosed of an autoimmune hepatitis treated previously with
The patient was immediately put in isolation for suspected
tuberculosis. CT scans showed bilateral intramuscular calf abscesses,
pleural effusion and a small intrasplenical abscess. Culture from the
pus aspirated from the calf produced a pseudomonal-like microorganism
that was bioquemically identified as _Burkhloderia pseudomallei_. All
mycobacterial stains and cultures continue to be negative. The
diagnosis of melioidiosis was confirmed by subsequent molecular
studies (specific PCR and hybridation techniques) at the National
Reference Laboratory for Spirochaete and Special Pathogens (CNM of
Majadahonda). The patient is receiving now IV ceftazidime.
After a careful risk assessment, health care personal and laboratory
personal who were in contact with the patient or the bacterial strain
are being followed and those with high risk exposures [such] as
intensive manipulation of cultures outside a biological safety
cabinet or preparation of liquid growth culture for antibiograms have
been put on cotrimoxazole [trimethoprim-sulfamethoxazole]
Diagnosis of melioidosis in patients coming from non-endemic
countries can be very elusive, specially in the tuberculosis-like
pulmonary forms, as _B. pseudomallei_ can be easily discarded as
colonizing upper respiratory tract flora of be misidentified as _B. cepacia_.
Dr. Juan Cuadros Gonzalez
Servicio de Microbiologica y Parasitologica
Hospital Principe de Asturias
[ProMED thanks Dr. Gonzalez for this fascinating, 1st-hand report.
Infection due to _Burkholderia pseudomallei_ (melioidosis) is
primarily endemic in focal areas of South East Asia and northern
Australia. _B. pseudomallei_ is deemed to be a category B biowarfare
agent. It is primarily an infection of humans with underlying
diseases such as alcoholism, malnutrition, cirrhosis, and
immunosuppression, but can also affect healthy individuals, as in
this report. In animal models, higher inocula can cause more serious
infection in immunocompetent individuals. Melioidosis is not a
zoonosis per se since although animals can and are infected,
transmission does not occur from animal to human, rather both are
Dance (1), at a time when the organism had Pseudomonas as its genus,
discussed the epidemiology of melioidosis outside of the classically
endemic areas. The following are the sections regarding Africa and
Europe with the citation numbers removed:
The possibility of the existence of melioidosis in Africa was 1st
raised in 1936 by Girard, who isolated a strain of _P. pseudomallei_
from the hemorrhagic submaxillary lymph node of a pig in
Madagascar....In 1969, melioidosis was reported in a goat in Chad.
Then, in 1972, Ferry isolated _P. pseudomallei_ from a number of pigs
in an abattoir in Niamey, Niger. These animals had been brought from
neighboring Upper Volta (Burkina Faso), and Dodin and Ferry were able
to isolate the organism from soil samples taken along the route that
the pigs had followed. They also demonstrated seropositivity in over
10 percent of serum samples from villagers in Upper Volta. At about
this time, Frazier found serological evidence that melioidosis might
exist in Uganda, while Mayer, as cited by Larionov, also reported the
occurrence of human melioidosis in Uganda....Further evidence of
melioidosis in Africa was provided by Bremmelgard, et al., who
reported a case of human melioidosis possibly acquired in Kenya, and
by Wall, et al., in The Gambia, the latter patient originating from
The most extraordinary extension of the boundaries of melioidosis
took place in France in the mid-1970s.....an epizootic of melioidosis
among animals in a Paris zoo was revealed. The outbreak subsequently
spread to other zoos in Paris and equestrian clubs throughout France
and beyong, probably by the transport of infected animals and
contaminated manure....Possibly, infected horses from Iran imported
the disease, or perhaps the index case was a panda donated to France
by Mao-Tse Tung in 1973...
"The isolation of _P. pseudomallei_ from horses in Spain has also
been reported, as have several possible cases of human melioidosis in
Berlin in 1947."
Although risk for occupational exposure to _B. pseudomallei_ in
clinical laboratories exists, laboratory-acquired infections are
rare. Laboratory exposures that have resulted in the most recent
cases of infection involved aerosols, alone or in combination with
exposure to nonintact skin (2). In one study, 3 cases of asymptomatic
seroconversion were reported among laboratorians in an area where
melioidosis is endemic, making difficult a determination of whether
infection resulted from occupational or environmental exposure (3).
CDC recommends that clinical specimens suspected of containing _B.
pseudomallei_ be manipulated using biosafety level (BSL)-2
containment practices, equipment, and facilities (4). Sniffing
culture plates is an unsafe laboratory procedure and should be
prohibited. Manipulations of an isolate that might result in aerosol
or droplet exposure or contact with nonintact skin should be
conducted using BSL-3 containment practices, equipment, and
facilities. In addition, improved communication between physicians
and laboratorians might reduce the risks to laboratorians. Laboratory
workers with high-risk exposures can be offered postexposure
prophylaxis with doxycycline (2 mg/kg up to 100 mg orally, twice
daily) or trimethoprim-sulfamethoxazole (8 plus 40 mg/kg, up to 320
plus 1600 mg orally, twice daily) (5), but the optimum duration of
treatment and its efficacy have not been defined clearly by human studies.
The readers are referred to a recent chapter on melioidosis, aimed to
its potential as a biowarfare agent (6).
1. Dance DAB: Melioidosis: the tip of the iceberg? Clin Micriobiol
Rev 1991;4: 52-60.
2. Sewell DL: Laboratory-associated infections and biosafety. Clin
Microbiol Rev 1995;8: 389-405.
3. Ashdown LR. Melioidosis and safety in the clinical laboratory. J
Hosp Infect 1992;21: 301-306
4. CDC: National Institutes of Health: Biosafety in microbiological
and biomedical laboratories, 4th ed. Washington DC: US Government
Printing Office; 1999.
5. CDC: Laboratory exposure to Burkholderia pseudomallei---Los
Angeles, California, 2003. MMWR 2004;53: 988-90.
6. Tolaney P, Lutwick LI: Melioidosis. In Beyond Anthrax: The
Weaponization of Infectious Diseases, Lutwick LI, Lutwick SM
(eds), Humana Press, Totowa, NJ, 2009, pp. 145-158.
[The interactive HealthMap/ProMED map of Spain is available at:
<http://healthmap.org/r/00dK> - CopyEd.EJP]