A traveller presenting with severe melioidosis complicated by a pericardial effusion: a case report

Schultze et al. BMC Infectious Diseases 2012, 12:242http://www.biomedcentral.com/1471-2334/12/242 A traveller presenting with severe melioidosiscomplicated by a pericardial effusion: a casereport Detlev Schultze1*, Brigitt Müller2, Thomas Bruderer1, Günter Dollenmaier1, Julia M Riehm3 and Katia Boggian4 Background: Burkholderia pseudomallei, the etiologic agent of melioidosis, is endemic to tropic regions, mainly inSoutheast Asia and northern Australia. Melioidosis occurs only sporadically in travellers returning fromdisease-endemic areas. Severe clinical disease is seen mostly in patients with alteration of immune status. Inparticular, pericardial effusion occurs in 1-3% of patients with melioidosis, confined to endemic regions. To our bestknowledge, this is the first reported case of melioidosis in a traveller complicated by a hemodynamically significantpericardial effusion without predisposing disease.
Case presentation: A 44-year-old Caucasian man developed pneumonia, with bilateral pleural effusions andcomplicated by a hemodynamically significant pericardial effusion, soon after his return from Thailand toSwitzerland. Cultures from different specimens including blood cultures turned out negative. Diagnosis was onlyaccomplished by isolation of Burkholderia pseudomallei from the pericardial aspirate, thus finally enabling theadequate antibiotic treatment.
Conclusions: Melioidosis is a great mimicker and physicians in non-endemic countries should be aware of itsvaried manifestations. In particular, melioidosis should be considered in differential diagnosis of pericardial effusionin travellers , even without risk factors predisposing to severe disease.
Keywords: Melioidosis, Burkholderia pseudomallei, Pericardial effusion, Traveller from December 2008 until February 2009. The general Melioidosis is a great mimicker and on clinical grounds it practitioner treated the patient for community-acquired is often impossible to differentiate it from other acute and pneumonia with amoxicillin-clavulanate for seven days.
chronic bacterial infections. Definite diagnosis relies on After initial improvement, the patient became febrile and isolation and identification of its causative agent, Burkhol- deria pseudomallei . In different endemic regions, On admission the patient was febrile (38.3°C), had a pericardial effusion occurs in 1-3% of patients with meli- tachycardia of 130 beats/minute, a blood pressure of oidosis . We present a case of severe melioidosis with a 120/78 mmHg, and a respiratory rate of 40/min.
hemodynamically significant pericardial effusion in a trav- Although the patient showed jugular venous disten- eller returning to a non-endemic region.
tion, neither Kussmaul’s sign nor hepatomegaly or per-ipheral oedema were observed.
Laboratory tests revealed anaemia (hemoglobin 125 g/l, A 44-year-old Caucasian man from Switzerland devel- hematocrit 0.37), leucocytosis, (16.6 G/l; 80% neutrophils, oped fever and productive cough, two weeks after return- 12% lymphocytes), elevated C-reactive protein (141 mg/l) ing from north-eastern Thailand, were he had stayed and elevated B-type natriuretic peptide (208 ng/l). Labora-tory screening for autoimmune diseases and vasculitis was negative. Electrocardiogram showed sinus tachycardia and 1Center of Laboratory Medicine, Frohbergstrasse 3, CH-9001 St. Gallen, SwitzerlandFull list of author information is available at the end of the article 2012 Schultze et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.
Schultze et al. BMC Infectious Diseases 2012, 12:242 http://www.biomedcentral.com/1471-2334/12/242 A chest radiograph showed bilateral pleural effusions Kit and a PRISM 3130 Genetic Analyzer (Applied and an enlarged cardiac silhouette. Computed tomog- Biosystems, Foster City, CA, USA) with sequence ana- raphy (CT) of the chest confirmed bilateral pleural effu- lysis by MicroSeq ID Microbial Identification Software sions, with atelectasis of the inferior lobes, mediastinal (Applied Biosystems, Foster City, CA, USA) confirmed lymphadenopathy and a prominent pericardial effusion.
the isolate as B. pseudomallei (DQ108392, 481-bp con- Abdominal CT showed a small intra-abdominal fluid sensus length). Multilocus sequence typing (MLST) of the isolate revealed the allelic profile 1/1/4/1/5/4/1, Echocardiography confirmed a hemodynamic relevant corresponding to B. pseudomallei sequence type 207, pericardial effusion with diastolic compression of the which has first been isolated from a patient in Thailand right ventricle and a leftventricular ejection fraction of with invasive melioidosis in 2001 The isolate was 55%. After pericardiocentesis and aspiration of 700 ml of sensitive to amoxicillin-clavulanate (2 μg/mL), ceftazidime a clear yellowish fluid the right ventricular function nor- (1.5 μg/mL), doxycycline (3 μg/mL) and trimethoprim- malized, the leftventricular ejection fraction raised to 65%, and the QRS voltage normalized.
testing was carried out by Etest (AB BIODISK, Sweden) Pleural effusion (1.07 G/l leucocytes, 33% monocytes/ and interpreted according to guidelines established by nuclear neutrophil leucocytes; LDH 144 U/l with normal The patient received ceftazidime 2 g every 6 hours for 2 range of LDH in serum <265 U/l ,and with a pleural weeks followed by maintenance treatment for three fluid/serum-quotient of 0.4 for LDH and 0.4 for total months with doxycycline, trimethoprim-sulfamethoxazole protein, respectively) was negative on Gram- and Ziehl- and leucovorine. The patient fully recovered after four Neelsen stains and negative by Polymerase Chain Reac- months and suffered no relapse in the two years follow-up.
tion Assay for Mycobacterium tuberculosis complex.
Cultures remained negative for bacteria, including myco- bacteria and fungi. Cultures of two sputum samples Our patient developed signs of respiratory illness within from the same day yielded normal upper respiratory the usual incubation period for melioidosis of 1-21 days, tract flora. Four sets of blood cultures taken on four shortly after leaving northeastern Thailand, an endemic consecutive days remained sterile and urine was negative region for this illness. As Switzerland is not among those countries, where autochthonous cases of melioidosis Pericardial effusion (1.4 G/l leucocytes, 58% monocytes/ have been reported the patient probably acquired macrophages, 23% lymphocytes, 19% polymorphonuclear the infection during his stay in Thailand.
neutrophil leucocytes; pericardial fluid/serum-quotient of Pneumonia results from haematogenous spread of 0.6 for total protein content and of 2.3 for LDH activity, B. pseudomallei to the lung following inoculation through respectively) was negative on Ziehl-Neelsen stain and exposure to muddy soils or surface water or alternatively mycobacterial cultures remained negative. Two blood by inhalation, as the two main modes of infection [.
culture sets were inoculated with pericardial aspirate Although melioidosis occurs in all age groups, severe (10 ml volume per bottle), and a Gram-negative bacillus clinical disease, such as septicaemic pneumonia, is seen was isolated from both aerobic bottles after 35 hours mostly in patients with alteration of immune status, e.g.
diabetes, chronic renal failure or alcoholism Our pa- (Becton Dickinson AG, Allschwil, Switzerland).
tient had neither a clinical risk factor for melioidosis nor Although identified as Burkholderia cepacia in a UNMIC/ ID-62 panel of the Phoenix Automated Microbiology Epidemiologic considerations are very important in System (Becton Dickinson AG, Allschwil, Switzerland), the management of pericardial effusion, as in devel- diagnosis was regarded as tentative, since identification oped countries acute idiopathic pericarditis and idio- of B. cepacia by common automated identification pathic pericardial effusion are the most common instruments should be confirmed by molecular tests etiologies, whereas in some underdeveloped geographic ]. Furthermore, pericardial effusion is an unusual areas tuberculous pericarditis is the leading cause of location for occurrence of B. cepacia and the isolate pericardial effusion In a systematic analysis of 106 was unexpectedly sensitive to amoxicillin-clavulanate pericardial fluid samples from France, a non-endemic country for melioidosis, B. pseudomallei was not 20NE biochemical test panel V7.0 (bioMérieux, Geneva, among the detected bacterial agents [Even in en- Switzerland) yielded Burkholderia pseudomallei (profile demic regions, pericardial effusion caused by B. pseu- 1156577; 99.9%, ID, 1.0 T). Amplification and sequen- domallei is a rare phenomenon. In the Darwin cing of a 500-bp fragment of the 16S rRNA gene by prospective melioidosis study from tropical Australia Fast MicroSeq 500 16S rDNA Bacterial Identification only four of 540 documented cases had pericarditis, Schultze et al. BMC Infectious Diseases 2012, 12:242 http://www.biomedcentral.com/1471-2334/12/242 three of them with pulmonary infection In a consent is available for review by the Editor-in-Chief of 10-years retrospective study from Thailand only 12 domestic cases of melioidosis complicated by culture-confirmed pericarditis were found. One-third of these patients had underlying diseases and two-third showed The authors declare that they have no competing interests.
evidence of bacteremia with secondary seeding in thepericardium In areas where tuberculosis and Authors’ contributionsDS supervised the microbiological analyses and wrote the manuscript. ThB, melioidosis are endemic, complicating pericarditis may GD, JMR supervised the microbiological analyses and helped to draft the only be differentiated by pericardial fluid culture and manuscript. BM and KB contributed to diagnosis and treatment and KB helped to draft the manuscript and did outpatient follow-up. All authorsread and approved the final manuscript.
As bacteremia could not be detected in our patient, B. pseudomallei might have gained access into the pericar- dium through the mediastinal lymph nodes in the course We are grateful to the patient for permission to publish this case report. The of pneumonia, known from patients with tuberculosis Center of Laboratory Medicine, St. Gallen, Switzerland and the BundeswehrInstitute of Microbiology, Munich, Germany funded the microbiological []. Cultures from different specimens remained negative analyses of the samples as part of the quality improvement program. No for B. pseudomallei. Only culture of pericardial fluid grew other, especially no commercial funding was received for the study.
the causative agent, possibly due to the use of blood cul- ture bottles as primary culture medium. Blood culture 1Center of Laboratory Medicine, Frohbergstrasse 3, CH-9001 St. Gallen, bottles are superior in performance to traditional plated- Switzerland. 2Department of Internal Medicine, Cantonal Hospital, medium methods for detection of microorganisms from Rorschacherstrasse 95, CH-9007 St Gallen, Switzerland. 3Bundeswehr Instituteof Microbiology, Neuherbergstr 11, D-80937 Munich, Germany. 4Department sterile body fluids Detection of B. pseudomallei from of Internal Medicine, Division of Infectious Diseases, Cantonal Hospital, nonsterile specimens such as sputum samples, can be Rorschacherstrasse 95, CH-9007 St Gallen, Switzerland.
hampered by the overgrowth and masking of B. pseudo- Received: 4 March 2012 Accepted: 1 October 2012 mallei by commensal flora, if selective culture media are not used, that are more common in medical laboratoriessituated in countries where the disease is endemic .
Cheng AC, Currie BJ: Melioidosis: epidemiology, pathophysiology and amoxicillin-clavulanate was certainly inadequate as an management. Clin Microbiol Rev 2005, 18:383–416.
Limmathurotsakul D, Peacock SJ: Melioidosis: a clinical overview. Br Med intensive phase therapy for melioidosis However, this may have been responsible for the absence of Gautam V, Singhal L, Ray P: Burkholderia cepacia complex: Beyond growth of B. pseudomallei in other samples, especially in pseudomonas and acinetobacter. Indian J Med Microbiol 2011,29:4–12.
blood culture. This may also explain why the patient did Weissert C, Dollenmaier G, Rafeiner P, Riehm J, Schultze D: Burkholderia not develop a septic shock as recently reported to be pseudomallei misidentified by automated system. Emerg Infect Dis 2009, very common in patients with primary pneumonia com- Godoy D, Randle G, Simpson AJ, Aanensen DM, Pitt TL, Kinoshita R, Spratt bined with positive blood culture The detection of BG: Multilocus sequence typing and evolutionary relationships among B. pseudomallei in the pericardial aspirate finally enabled the causative agents of melioidosis and glanders, Burkholderia the adequate, although delayed antibiotic treatment, pseudomallei and Burkholderia mallei. J Clin Microbiol 2003,41(5):2068–2079.
Multi locus sequence typing (MLST): London: Imperial College London;2008. cited 2008 Nov 24. mlst.net.
Clinical and Laboratory Standards Institute: Performance standards for antimicrobial susceptibility testing; 18th informational supplement, document Melioidosis is a great mimicker and physicians in non- Currie BJ: Melioidosis: an important cause of pneumonia in residents of endemic countries like Switzerland should be aware of and travellers returned from endemic regions. Eur Respir J 2003, its varied manifestations. In particular, melioidosis should be considered in the differential diagnosis of peri- Sagristà-Sauleda J, Mercé AS, Soler-Soler J: Diagnosis and management ofpericardial effusion. World J Cardiol 2011, 3(5):135–143.
cardial effusion in travellers, even in the absence of risk Levy PY, Fournier PE, Charrel R, Metras D, Habib G, Raoult D: Molecular factors predisposing to severe disease. To our best analysis of pericardial fluid: a 7-year experience. Eur Heart J 2006, knowledge, this is the first reported case of melioidosis Currie BJ, Ward L, Cheng AC: The epidemiology and clinical spectrum of in a traveller complicated by a hemodynamically signifi- melioidosis: 540 cases from the 20 year Darwin prospective study.
Chetchotisakd PS, Anunnatsiri S, Kiatchoosakun S, Kularbkaew C: Melioidosispericarditis mimicking tuberculous pericarditis. Clin Infect Dis 2010, Chung HC, Lee CT, Lai CH, Huang CK, Lin JN, Liang SH, Lin HH: Case Written informed consent was obtained from the patient Report: Non-septicemic melioidosis presenting as cardiac tamponade.
for publication of this case report. A copy of the written Schultze et al. BMC Infectious Diseases 2012, 12:242 http://www.biomedcentral.com/1471-2334/12/242 Bourbeau P, Riley J, Heiter BJ, Master R, Young C, Pierson C: Use of theBacT/Alert Blood Culture System for Culture of Sterile Body Fluids Otherthan Blood. J Clin Microbiol 1998, 36(11):3273–3277.
Meumann EM, Cheng AC, Ward L, Currie BJ: Clinical features andepidemiology of melioidosis pneumonia: results from a21-year study and review of the literature. Clin Infect Dis 2012,54(3):362–369.
doi:10.1186/1471-2334-12-242Cite this article as: Schultze et al.: A traveller presenting with severemelioidosis complicated by a pericardial effusion: a case report. BMCInfectious Diseases 2012 12:242.
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Ben's notes

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