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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2020  |  Volume : 31  |  Issue : 6  |  Page : 1411-1414
Septicemic melioidosis complicating undiagnosed chronic kidney disease and beta-thalassemia minor in a Bangladeshi farmer


Department of Nephrology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh

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Date of Web Publication29-Jan-2021
 

   Abstract 


Melioidosis is an emerging infectious disease in many countries including Bangladesh. Patients with diabetes mellitus are at increased risk for infection by Burkholderia pseudomallei, the causative agent for melioidosis. Here, we report an autochthonous case of septicemic melioidosis occurring in a middle-aged non-diabetic Bangladeshi farmer who presented with prolonged pyrexia and splenomegaly. Diagnostic workup revealed splenic micro-abscesses, previously undetected chronic kidney disease (CKD) and beta-thalassemia minor. This case stresses the importance of searching for less common risk factors for melioidosis such as CKD and hemolytic anemia.

How to cite this article:
Rahim MA, Khan MA, Chowdhury TA, Ananna MA. Septicemic melioidosis complicating undiagnosed chronic kidney disease and beta-thalassemia minor in a Bangladeshi farmer. Saudi J Kidney Dis Transpl 2020;31:1411-4

How to cite this URL:
Rahim MA, Khan MA, Chowdhury TA, Ananna MA. Septicemic melioidosis complicating undiagnosed chronic kidney disease and beta-thalassemia minor in a Bangladeshi farmer. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Mar 4];31:1411-4. Available from: https://www.sjkdt.org/text.asp?2020/31/6/1411/308358



   Introduction Top


Melioidosis is endemic in south-east Asia and northern Australia, but sporadic and imported cases are reported elsewhere.[1],[2] There is increasing evidence of the expansion of the geographic distribution of Burkholderia pseudomallei, the causative organism for melioidosis.[2] Melioidosis is an emerging infectious disease in Bangladesh.[3] Patients with diabetes mellitus are at increased risk for melioidosis.[2],[3] Isolation of B. pseudomallei from the environment has confirmed Bangladesh as endemic for melioidosis[4] though clinical cases were occasionally reported.[2],[5],[6] We report an autochthonous case of melioidosis occurring in a non-diabetic Bangladeshi farmer who presented with prolonged pyrexia and splenomegaly. This infective episode helped to unveil that he had chronic kidney disease (CKD) and beta-thalassemia minor.


   Case Report Top


A 55-year-old Bangladeshi farmer, not known to be diabetic, got admitted with a 5-month history of fever, anorexia and 11 -kg weight loss. Over this period, he consulted several physicians, underwent various investigations and received several courses of antibiotics without much benefit and no definite diagnosis could be established. He never traveled outside Bangladesh and denied any high-risk sexual activity. The man was looking very ill and was wasted and anemic. He had 4-cm splenomegaly below the left subcostal margin and crepitations on lung auscultation.

He had anemia (hemoglobin 8.7 g/dL) with low mean corpuscular volume (61 fl), neutrophil leukocytosis (total white cells 17,100/mm3, neutrophils 87%), thrombocytopenia (21,000/ mm3), high erythrocyte sedimentation rate (77 mm/1st h) and C-reactive protein (126 mg/L). Chest X-ray revealed bilateral pulmonary infiltrates [Figure 1]. Ultrasonography showed 15-cm splenomegaly with micro-abscesses and echogenic kidneys. Non-contrast computed tomography scan showed hepato-splenomegaly with splenic abscesses [Figure 2]a and [Figure 2]b and small kidneys. Urine routine examination showed plenty of pus cells/high power field, serum creatinine was 8.1 mg/dL, random blood glucose was 5.2 mmol/L and glycated hemoglobin was 5.9%. Blood culture grew B. pseudomallei [Figure 3], while urine and sputum appeared sterile. Hemoglobin electro-phoresis revealed beta-thalassemia minor.
Figure 1: Chest X-ray postero-anterior view showing bilateral pulmonary infiltrates.

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Figure 2: (a and b) Non-contrast computed tomography scan of abdomen showing splenomegaly with abscesses.

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Figure 3: Blood culture showing growth of Burkholderia pseudomallei.

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He was started with meropenem (dose adjusted for kidney function) and continued for four weeks. Co-trimoxazole and doxycycline were added in eradication phase. Initially, he required three sessions of hemodialysis and three units of blood transfusion. Other medications included paracetamol and folic acid. He was discharged after 31 days of admission in afebrile state with oral medications and stable kidney function (serum creatinine 3.2 mg/dL without dialysis). He completed 22-weeks of oral antibiotics with periodic follow-up without any adverse effects, without deterioration of renal function and recurrence of symptoms.

Informed consent was obtained from the patient for the publication of this case report.


   Discussion Top


Melioidosis is an uncommon but emerging infection in Bangladesh.[3] Sero-epidemiological surveillance reports,[4],[7] organism isolation from soil specimens[4] and autochthonous cases[3],[5] established Bangladesh as endemic for melioidosis.

Patients with B. pseudomallei infection may present with fever, pneumonia, cutaneous and visceral abscess and septic arthritis.[3],[6] Splenic abscess is usually a consequence of septicemic melioidosis and rarely splenic rupture may occur.[8],[9] Clinical presentation of melioidosis often mimics tuberculosis[10] and it is not unlikely that in nonendemic regions many patients are empirically treated with antituberculosis drugs, resulting in unfavorable outcome.

Most patients with melioidosis have underlying conditions such as diabetes mellitus, CKD, alcoholism, malignancy or immunosup-pressive conditions, receiving chemotherapy, organ transplant recipients and taking immuno-suppressive drugs.[2],[3],[5],[11] Thalassemia is also a recognized risk factor for melioidosis, especially in childhood cases.[12],[13] Our patient being a farmer was at risk for being infected by B. pseudomallei. He was non-diabetic, but had two other potential but unidentified risk factors for melioidosis in him, like CKD and thalassemia.

Identification of B. pseudomallei from blood and other specimens in culture remains the gold standard in diagnosing melioidosis. Often culture specimens are discarded as contamination from microbiology laboratories.[3] High index of clinical suspicion is important and good communication between treating physician and microbiology laboratory is important, especially in countries like Bangladesh, where melioidosis is emerging and tuberculosis is endemic.[3] Failure to suspect fairly earlier in the disease course, delay in diagnosing and initiating appropriate antibiotics remain as major causes of death in melioidosis. Hence, a high index of clinical suspicion is emphasized.

In conclusion, melioidosis should be a differential diagnosis in any patient with fever, organomegaly and internal organ abscess, especially if occurring in a farmer and having risk factors such as diabetes, thalassemia or CKD and especially if not responding to commonly prescribed antibiotics.


   Acknowledgment Top


The authors would like to thank Dr. Lovely Barai, Associate Professor of Microbiology, BIRDEM General Hospital, for guiding antibiotic selection for the patient.

Conflict of interest: None declared.



 
   References Top

1.
Limmathurotsakul D, Golding N, Dance DA, et al. Predicted global distribution of Burkholderia pseudomallei and burden of melioidosis. Nat Microbiol 2016;1:pii:15008.  Back to cited text no. 1
    
2.
Tamtami NA, Khamis F, Al-Jardani A. Imported case of melioidosis in Oman: Case report. Oman Med J 2017;32:62-5.  Back to cited text no. 2
    
3.
Rahim MA, Afroze SR, Barai L, Uddin KN. Melioidosis: Truly uncommon or uncommonly diagnosed in Bangladesh? A case report. Birdem Med J 2015;5 Suppl 1:49-51.  Back to cited text no. 3
    
4.
Jilani MS, Robayet JA, Mohiuddin M, Hasan MR, Ahsan CR, Haq JA. Burkholderia pseudomallei: Its detection in soil and seroprevalence in Bangladesh. PLoS Negl Trop Dis 2016;10:e0004301.  Back to cited text no. 4
    
5.
Rahim MA, Samad T, Ananna MA, Ul Haque MM. Genitourinary melioidosis in a Bangladeshi farmer with IgA nephropathy complicated by steroid-induced diabetes mellitus. Saudi J Kidney Dis Transpl 2018;29: 709-13.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Afroze SR, Barai L, Rahim MA, et al. Socio-demographic, clinical and laboratory characteristics of melioidosis: Four-year experience of managing consecutive 11 cases in a tertiary care hospital of Bangladesh. BIRDEM Med J 2017;7:28-37.  Back to cited text no. 6
    
7.
Maude RR, Maude RJ, Ghose A, et al. Sero-epidemiological surveillance of Burkholderia pseudomallei in Bangladesh. Trans R Soc Trop Med Hyg 2012;106:576-8.  Back to cited text no. 7
    
8.
Satayraddi A, Cherian KE, Kapoor N, Rupali P, Paul TV. Multiple visceral abscesses in a patient with diabetes mellitus: A rare yet corrigible infection: Melioidosis. Trop Doct 2018;48:54-6.  Back to cited text no. 8
    
9.
Miraclin AT, Mani SS, Suresh S, Iyyadurai R. Septicemic melioidosis with ruptured splenic abscess in a patient with thalassemia intermedia. J Glob Infect Dis 2017;9:32-3.  Back to cited text no. 9
    
10.
Chow TK, Eu LC, Chin KF, et al. Incidental splenic granuloma due to Burkholderia pseudomallei: A case of asymptomatic latent melioidosis? Am J Trop Med Hyg 2016;94: 522-4.  Back to cited text no. 10
    
11.
Sathiavageesan S. Septicemic melioidosis in a transplant recipient causing graft dysfunction. Indian J Nephrol 2016;26:379-82.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Fong SM, Wong KJ, Fukushima M, Yeo TW. Thalassemia major is a major risk factor for pediatric melioidosis in Kota Kinabalu, Sabah, Malaysia. Clin Infect Dis 2015;60:1802-7.  Back to cited text no. 12
    
13.
Suputtamongkol Y, Chaowagul W, Chetchotisakd P, et al. Risk factors for melioidosis and bacteremic melioidosis. Clin Infect Dis 1999;29:408-13.  Back to cited text no. 13
    

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Correspondence Address:
Muhammad Abdur Rahim
Department of Nephrology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka
Bangladesh
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DOI: 10.4103/1319-2442.308358

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    Abstract
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