travel-associated Melioidosis cutaneous
Melioidosis: Belgium - exThailand
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.
Case Report:
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.
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. Link and further information vailable at: http://www.medicalqm.com/news/melioidosis/index.html.
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.
(09. Oct. 2012 - red)
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