History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include: occupational/recreational environmental exposure, diabetes, hazardous alcohol use, chronic renal disease, malignancy and immunosuppressive therapy, thalassaemia, and cystic fibrosis and other chronic lung disease.

fever/sweats

Occurs in most, but not all, cases. Duration can be days or weeks, depending on severity.

About 10% of cases have a chronic illness (defined as symptomatic for >2 months) that often mimics, and is misdiagnosed as pulmonary tuberculosis.[7][64]

cough

May or may not present with sputum production.

Over 50% of all cases present with community-acquired pneumonia.[37][64]

About 10% of cases have a chronic illness (defined as symptomatic for >2 months) that often mimics, and is misdiagnosed as pulmonary tuberculosis.[7][64]

septic shock

Up to 25% of all cases have critical sepsis.[65][79]

regional lymphadenitis/parotitis

Up to 15% of cases have only localised disease (especially children).[9]

Parotitis, usually unilateral, is one of the most common presentations in children in Southeast Asia, but is very rare in Australia.[7][11][12]

uncommon

non-healing skin sore/ulcer or abscess

Up to 15% of cases have only localised disease (especially children).[9]

Patients can present with single non-healing skin ulcers/abscesses.[9] This is more common in children and those with no risk factors for melioidosis.[10]

bacteraemia without evident clinical focus

Present in up to 15% of cases.[7]

lower motor neuron cranial nerve palsies (especially cranial nerves VII and VIII)

Rare but important in melioidosis brainstem encephalitis.[10][17][18][80]

flaccid paralysis

Rare but important in melioidosis myelitis.[10][17][18][80]

Other diagnostic factors

common

shortness of breath

Over 50% of all cases present with community-acquired pneumonia.[37][64]

uncommon

abdominal pain/diarrhoea

Prostatic abscesses occur in up to 20% of males with melioidosis.[81]

dysuria

Prostatic abscesses occur in up to 20% of males with melioidosis.[81]

urinary retention

Prostatic abscesses occur in up to 20% of males with melioidosis.[81]

other signs of organ abscess

Internal organ abscesses may be present (e.g.,prostate, muscle, liver, spleen, lung, brain), and signs will depend on location of abscess.

altered conscious state

Rare but important in melioidosis brainstem encephalitis.[10][17][18][80]

arthritis/osteomyelitis

Septic arthritis and/or osteomyelitis can rarely be the primary presentation of melioidosis, but are more common as secondary manifestations that appear clinically a week or more into therapy for melioidosis, presenting as pneumonia or other sepsis.[13]

A case of a patient presenting with spondylodiscitis has been reported.[14]

CNS meliodosis may present as osteomyelitis.[15]

mycotic pseudo-aneurysms

Mycotic pseudo-aneurysms of usually atherosclerotic major arteries (most commonly the abdominal aorta) are a rare but life-threatening primary or secondary clinical manifestation of melioidosis that requires urgent referral to a vascular surgeon.[21]

Risk factors

strong

travel to endemic area

Melioidosis has traditionally been thought of as a disease of Southeast Asia and northern Australia, but over the past 20 years it has been increasingly recognised throughout the tropics, including the Indian subcontinent, sub-Saharan Africa, and Central and South America and the Caribbean.[24] Infection can occur in travellers from these locations, and has also been reported in non-endemic countries including France, the Netherlands, the US, Saudi Arabia, and China.[26][27][28][29][30]

occupational/recreational environmental exposure

Infection requires exposure to the bacteria from soil, water, or aerosol contact in a melioidosis-endemic region (e.g., rice farmers, those working outdoors with soil and water contact, those drinking unchlorinated water, gardening, tourist activities with exposure to muddy water and soil, severe weather events such as cyclones, hurricanes, and typhoons with inhalation).[34][37][38][39][44][45][46][47][48][49]

diabetes

About 40% to 60% of confirmed melioidosis patients have type 1 or type 2 diabetes.[7][8][50][51] Poor diabetic control increases the risk.

hazardous alcohol use

Up to 40% of melioidosis cases in some series consume more alcohol than the daily average.[7] This probably relates to the effect of high blood alcohol levels on innate immune defence against infection with Burkholderia pseudomallei.

chronic renal or liver disease

May predispose patients to melioidosis. Chronic renal failure or renal stones are present in up to 27% of cases.[7][50][51]

malignancy and immunosuppressive therapy

High-dose corticosteroid therapy is an example.[7] The link to biological agents is uncertain but 2 cases were documented after adalimumab therapy.[52]

thalassaemia

Likely related to iron overload.[53]

cystic fibrosis and other chronic lung disease

Some authorities recommend people with cystic fibrosis avoid travel to melioidosis-endemic regions.[54]

weak

bioterrorism

Both organisms have been considered as potential biological weapons, and glanders was used deliberately by German agents in World War I.[4] They are classified as Tier 1 select agents in the US as they present the greatest risk of deliberate misuse with significant potential for mass casualties or devastating effect to the economy, critical infrastructure, or public confidence, and pose a severe threat to public health and safety.[5]

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