A Case of Melioidosis with Multiple Lung Abscesses, Intrahepatic Cholestasis and Hepatic Encephalopathy

Case Report

J Bacteriol Mycol. 2017; 4(2): 1048.

A Case of Melioidosis with Multiple Lung Abscesses, Intrahepatic Cholestasis and Hepatic Encephalopathy

Palangasinghe DR¹*, Jayasekara S², Hewavithana J¹, Dahanayaka N³ and Bodinayake C³

¹Senior Registrar in Medicine, University Medical Unit, Teaching Hospital Karapitya, Galle, Sri Lanka

²Registrar in Medicine, University Medical Unit, Teaching Hospital Karapitiya, Galle, Sri Lanka

³Senior Lecturer in Medicine, Consultant Physician, Faculty of Medicine, University of Ruhuna, Sri Lanka

*Corresponding author: Dhammika Randula Palangasinghe, Senior Registrar in Medicine, University Medical Unit, Teaching Hospital Karapitya, Galle, Sri Lanka

Received: March 29, 2017; Accepted: April 19, 2017; Published: April 26, 2017


Background: Melioidosis is an infectious disease caused by gram negative bacillus Burkholderia pseudomallei. It is an emerging infection in Sri Lanka and the clinical presentation is not distinctive. We report a case of melioidosis with multiple lung abscesses, intrahepatic cholestasis and hepatic encephalopathy.

Case Presentation: A 56 year old diagnosed patient with type 2 diabetes mellitus, Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP), benign prostatic hypertrophy admitted with high fever with chills and rigors for five days followed by worsening lower limb weakness with acute urine retention. On examination he was emaciated, deeply icteric and febrile, having flapping tremors, with grade 2 weakness, areflexia in lower limbs with a palpable bladder. Three consecutive blood cultures were positive for Burkholderia pseudomallei with multiple bilateral lung abscesses seen on chest radiograph. His magnetic resonance imaging of the lumbosacral spine was normal with evidence of CIDP in the nerve conduction studies. He responded well to intravenous meropenam, oral co-trimoxazole with complete resolution of fever, conscious level and liver functions.

Conclusion: Melioidosis is a treatable emerging infection having high morbidity and mortality with wide array of complications including intrahepatic cholestasis. We achieved an excellent response with early antibiotic therapy resulting in complete resolution of fever and liver functions.

Keywords: Melioidosis; Intrahepatic cholestasis; Hepatic encephalopathy; Multiple lung abscesses


Melioidosis is caused by a saprophytic bacterium, Burkholderia pseudomallei which is gram negative bacillus and is acquired by inoculation or inhalation of contaminated soil/water. Occupational exposure to surface water and mud is a risk factor. Since the presentation of melioidosis range from localized abscesses in skin, soft tissues and lungs to disseminated disease with septicaemia a high index of suspicion is required to diagnose the infection early [1-3].

Melioidosis is frequently reported in South East Asia and Northern Australia [4]. It also occurs in South Pacific, Africa, India, and the Middle East. Sri Lanka lies in the melioidosis belt. Although Sri Lanka is not considered as a country where melioidosis is endemic, an increasing number of cases have been reported recently [5]. Only three cases had been reported between 1927 and 2005 but there were approximately 90 patients detected from 2006 to 2015 in Sri Lanka [4]. The number rose every year, with 70% detected in 2014/15. Case detection was improved by raising physician, microbiologist and laboratory technician awareness [4]. Cases presented throughout the year with two peaks during monsoons which is probably secondary to increased risk of inhalation related to rainfalls [4]. Still there is a need to increase the awareness regarding this infection among clinicians and clinical microbiologists in addition to improve laboratory facilities if we are to diagnose more cases early followed by appropriate antibiotic therapy since that is the best way to reduce the mortality which was estimated to be about 40% in 2015 [5].

The clinical presentation is not distinctive and varied. It may be acute or chronic, localized or disseminated. Severe infection is more common in persons with diabetes mellitus, chronic kidney disease, liver disease and alcoholism. Occupational exposure to mud and surface water have made paddy farmers, other cultivators, military personnel, construction workers, livestock farmers and even those who indulge in gardening at higher risk of acquiring the infection.

Isolation of the causative bacterium in the clinical specimens (blood, urine, sputum, or skin-lesion sample) is the gold standard for the definitive diagnosis. Serologic testing alone is inadequate for confirming the diagnosis, especially in endemic regions where the background sero positivity rate can be more than 50% [5,6].

Melioidosis infection commonly involves the lungs and any organ can be involved with abscess formation. We are reporting a case of melioidosis with multiple lung abscesses and intrahepatic cholestasis with hepatic encephalopathy which fully resolved with appropriate antibiotic treatment.

Case Presentation

A 56 year old Sri Lankan carpenter from Galle, with a background history of type 2 diabetes mellitus presented with dysuria, lower abdominal pain, straining at micturition, poor stream followed by fever with chills and rigors for five days duration. Urinalysis revealed field full of pus cells with 5-10 red cells in high power field and a urine culture growing >105 colony forming units from coliforms sensitive for meropenem but resistant for gentamicin. His blood culture did not reveal any growth and he was treated with intravenous meropenam 1g three times daily for seven days. His fever and lower urinary tract symptoms resolved on day 4 of the treatment. Ultrasound scan of the abdomen revealed evidence of horseshoe shaped kidney with no evidence of pyelonephritis, perinephric-abscess or hydronephrosis and there was mild prostatomegaly without focal lesions. His serum creatinine value was within normal limits. He was sent home after seven days of antibiotic therapy when he was a febrile for three consecutive days. Five days later fever reappeared with chills and rigors. He again developed similar lower urinary tract symptoms, severe anorexia and nausea followed by acute urine retention. In addition he developed yellowish discoloration of the eyes with inversion of sleep pattern. He also developed worsening lower limb weakness over one week where he became bed bound in background history of gradually worsening lower limb numbness and weakness over last two months. On second admission he was found to be febrile (104 F), drowsy, deeply icteric, having flapping tremors. He was not pale and had no lymphadenopathy. He was tachycardic with pulse rate of 104/min and blood pressure was110/70 mmHg. There were no cardiac murmurs. He had coarse crepitations in the mid zone of the left lung. Abdominal examination revealed a palpable bladder with 400 mL of urine appearing with the catheterization. There was no hepatosplenomegaly. There was grade 2 weakness in the both lower limbs with areflexia with objective stocking type of sensory loss on both feet.

His haematological investigations revealed neutrophil leukocytosis (18.95×103 /μl; N-88%), elevated inflammatory markers (CRP 333 mg/dl; ESR 108 mm 1st hour). Initial chest radiograph showed left mid zone cavitating lesion. However repeat chest radiograph performed five days later showed bilateral multiple cavitating lesions compatible with multiple lung abscesses. There were no vegetations in the 2D echocardiogram (Figure 1-3).