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Published Date: 2012-10-07 13:03:18
Subject: PRO/EDR> Melioidosis - Belgium ex Thailand: cutaneous, travel-assoc.
Archive Number: 20121007.1329106

MELIOIDOSIS - BELGIUM ex THAILAND: CUTANEOUS, TRAVEL-ASSOCIATED
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Date: Wed 3 Oct 2012
From: Pierre Wattiau <Pierre.Wattiau@coda-cerva.be> [edited]

A 60-year-old female patient, who just returned after a sojourn in Thailand, came to her GP with the following symptoms: an ulcerated lesion on her leg that resisted treatment with common disinfectants. Bacterial cultures derived from pus sampled on 3 Sep 2012 from the ulcerated lesion yielded a bacterium that was identified as _Burkholderia pseudomallei_ with a 99 percent probability score by automated biochemical testing (VITEK 2, Biomerieux).

The suspect strain was sent to the national Reference laboratory at CODA-CERVA (Brussels), where _B. pseudomallei_ was confirmed on 12 Sep 2012 using highly specific molecular methods (ref: Wattiau et al. J. Clin. Microbiol 2007 45:1045-48). The strain was further analysed on a VITEK2 system for its antibiotic susceptibility profile and confirmed by disk-diffusion. This isolate of _B. pseudomallei_ was found to be susceptible to ceftazidime, imipenem, trimethoprim/sulfamethoxazole, amoxicillin/clavulanic acid, and doxycycline. The isolate was resistant to amikacin and polymyxin. The patient is being treated with amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole.

_B. pseudomallei_ is a soil bacterium endemic in Southeast Asia. Human contamination often occurs through direct contact with contaminated soil or water and is known to be favoured during the rainy season, which usually lasts from May to October. The bacterium typically enters the body through pre-existing cutaneous lesions, including minor trauma such as insect bites, and develops in the wound. If not treated, the infection may rapidly become systemic and cause a febrile disease with various presentations that range from acute septicaemia to a chronic infection with multi-organ involvement, which are often fatal.

A previous report of _B. pseudomallei_ infection in Belgium that dates back to 2003 consisted of a non-healing erythematous and ulcerated cutaneous lesion found on the arm of 90-year-old patient with no febrile symptoms. The patient had returned from a 3-week journey in northwest Bangladesh during the rainy season (Ezzedine K, Heenen M, Malvy D. Imported Cutaneous Melioidosis in Traveler, Belgium. Emerg Infect Dis 2007;13(6):946-947. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2792863/). [Pictures of the skin lesions in this patient are available at this URL.]

Clinicians should consider melioidosis in the differential diagnosis of febrile illnesses and isolated skin ulcers observed in travelers returning from Southeast Asia, especially during the rainy season. Biopsies of the cutaneous lesions should be taken as early as possible, preferentially before starting the antibiotic therapy, and analysed using adapted methodologies in containment level 3 facilities.

--
Joachim Steenbergen
Service of Microbiology (Head), AML Medical
Laboratory, Antwerp, Belgium

Johan Beert, MD
Service of Microbiology, AML Medical Laboratory,
Antwerp, Belgium

Pierre Wattiau, PhD
Highly Pathogenic & Foodborne Zoonoses (Head),
Veterinary & Agrochemical Research Center (CODA-CERVA)
Operational Direction Bacterial Diseases, Groeselenberg 99 B-1180
Brussels, Belgium
<Pierre.Wattiau@coda-cerva.be>

[ProMED very much appreciates this report of travel-associated cutaneous melioidosis from the Belgium authorities. Most imported cases have been said to have pulmonary or systemic involvement associated with a poor prognosis, but also isolated cutaneous ulcers, without fever have been reported (Ezzedine K, Heenen M, Malvy D. Imported Cutaneous Melioidosis in Traveler, Belgium. Emerg Infect Dis 2007;13(6):946-947. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2792863/).

With the increase in international travel and ecotourism, melioidosis is likely to become more common among travelers to melioidosis-endemic regions. This report serves as a reminder to clinicians who treat patients returning from disease-endemic tropical areas to consider meliodosis in the differential diagnosis in febrile illnesses and isolated skin ulcers without any systemic involvement.

The following has been extracted from moderator LL's comments in ProMED-mail post Melioidosis - Australia (04): (NT) cases increase 20120814.1243818:

_Burkholderia pseudomallei_ exists as an environmental saprophyte living in soil and surface water in endemic areas (Southeast Asia and northern, tropical Australia), particularly in rice paddies. In endemic countries, the organism exists primarily in focal areas and is not equally distributed throughout the landscape. Sporadic cases have been reported to have been acquired in parts of Africa and the Americas. The organism may exist in a viable, non-cultivable state in the environment, interacting with other organisms, particularly protozoa, which might explain its adaptation to an intracellular niche. Two outbreaks in Australia have also implicated potable water supplies rather than surface water as a potential source of the infection.

Melioidosis is a disease of the rainy season in the endemic areas. It mainly affects people who have direct contact with soil and water. Many have an underlying predisposing condition such as diabetes (commonest risk factor), renal disease, cirrhosis, thalassemia, alcohol dependence, immunosuppressive therapy, chronic obstructive lung disease, cystic fibrosis, and excess kava consumption. Kava is an herbal member of the pepper family that can be associated with chronic liver disease.

Melioidosis may present at any age but peaks in the 4th and 5th decades of life, affecting men more than women. In addition, although severe fulminating infection can and does occur in healthy individuals, severe disease and fatalities are much less common in those without risk factors.

The most commonly recognized presentation of melioidosis is pneumonia, associated with high fever, significant muscle aches, chest pain, and -- although the cough can be nonproductive -- respiratory secretions can be purulent, significant in quantity, and associated with on-and-off bright, red blood. The lung infection can be rapidly fatal -- with bacteremia and shock -- or somewhat more indolent.

Acute melioidosis septicemia is the most severe complication of the infection. It presents as a typical sepsis syndrome with hypotension, high cardiac output, and low systemic vascular resistance. In many cases, a primary focus in the soft tissues or lung can be found. The syndrome, usually in patients with risk factor co-morbidities, is characteristically associated with multiple abscesses involving the cutaneous tissues, the lung, the liver, and spleen, and a very high mortality rate of 80 to 95 per cent. With prompt optimal therapy, the case fatality rate can be decreased to 40 to 50 per cent.

_B. pseudomallei_ is usually inhibited by tetracyclines, chloramphenicol, trimethoprim/sulfamethoxazole (SXT), anti-pseudomonal penicillins, carbapenems, ceftazidime, and amoxicillin/clavulanate or ampicillin/sulbactam. Ceftriaxone and cefotaxime have good in vitro activity but poor efficacy; and cefepime did not appear, as well, to be equivalent to ceftazidime in a mouse model. The unusual antimicrobial profile of resistance to colistin and polymyxin B and the aminoglycosides, but sensitivity to amoxicillin/clavulanate is a useful tool to consider in treatment of infection with the organism.

The randomized and quasi-randomized trials comparing melioidosis treatments have been reviewed, and it was found that the formerly standard therapy of chloramphenicol, doxycycline, and SXT combination had a higher mortality rate than therapy with ceftazidime, imipenem/cilastatin, or amoxicillin/clavulanate (or ampicillin/sulbactam). The beta-lactam/beta-lactamase inhibitor therapy, however, seemed to have a higher failure rate.

The HealthMap/ProMED-mail interactive map of Belgium is available at http://healthmap.org/r/3wCR. - Mod.ML]

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