Septicemic melioidosis in Southern Taiwan: a case report

The patient was a 56 year-old man, a resident of Hen-Tsueng Township in Ping-Tung County. He worked as a ranger at Ken-Ting Farm in southern Taiwan, and had been to Thailand for sight-seeing 5 years ago. He came to our outpatient department about one month prior to hospitalization for intermittent fever of one week duration. At that time, complete blood count was within normal limits and a chest roentgenogram was unremarkable. He was given erythromycin without showing any clinical improvement. Two days prior to admission, he noted pain in the left hip. The next day, severe dyspnea developed suddenly and chest x-ray film revealed bilateral nodular lesions. Physical examination on hospitalization revealed an acutely ill and jaundiced male with a temperature of 37.4 degrees C, blood pressure: 110/47 mmHg, pulse rate: 137/min, and respiratory rate: 26/min. There were rales in both lungs, but no lymphadenopathy or organ enlargement. Laboratory study showed WBC: 1,470/mm(3), platelet count: 47,000/mm(3), blood sugar: 226 mg/dL, mildly elevated transaminases and bilirubin, and BUN: 69 mg/dL, Cr: 4.3 mg/dL. Arterial blood gas analysis indicated an acute metabolic acidosis with PaO2 of 32 mmHg. Despite the initial impression of melioidosis and administration of ceftazidime plus gentamicin, his condition rapidly deteriorated and expired 18 hours after admission. Two sets of blood cultures grew Burkholderia pseudomallei. Melioidosis has been called a great imitator of diseases and culture results are frequently misinterpreted. The mortality is high even with suggested therapy with ceftazidime, cotrimoxazole, amoxicillin-clavulanate, chloramphenicol, and/or tetracycline. There has been a total of 10 cases reported in southern Taiwan and 2 of them were clearly indigenous. Melioidosis should be included in the reportable diseases, and its prevalence in Taiwan also should be investigated.