Case write-up

44 years old malay male, a tailor from melaka. He has diabetes mellitus for 10 years, a smoker for the past 20 years. He presented with a upper anterior midline chest swelling for 3 weeks, swelling at dorsal aspect of right foot for 2 weeks. Fever and cough for 2 weeks.

Swelling at the chest was associated with pain. Initially a size of a 50 cent which progrsivelly increase to the size of a lemon. No discharged. He has difficulty in breathing when he is sleeping and occasional has dysphagia.
Swelling at right is also associated with pain and redness. Size of a ping pong ball. No ulcer or discharge. Incision and drainage has been done 1 week ago.
Fever was high grade which progrsivelly worsens, associated with chills and rigors, with night sweats as wel.
Cough was non-productive, no shortness of breath, no chest pain.

Systemic review was unremarkable.
Patient has diabetes mellitus for 10 years, on oral hypoglycemic (sulphanylurea), uncontrolled because occationally forgets to take medication uncontrol diet and continue smoking.

On general examination, he is tachypneac and has pallor and icterus.
local examination of the chest swelling, it is 11cm x 8cm, tender, local rise of temperature, firm, skin over swelling is red. Non-mobile, margins well define, skin over swelling is pinchable. No pulsations and punctum.
Respiratory system, at the mammary and infra-mammary area on both sides reveals diminished vocal fremitus, dull on percussion, crepitations and bronchial breathing.
CNS examintion reveals reduce vibration sense on left foot, ankle reflex absent on left side.
Other systems are normal.

At the end of discussion at bedside,diagnosis was Acute bronchitis with acute abscesses at upper sternal area and at right foot with uncontrolled type 2 DM with peripheral large fibre neuropathy.

Lab investigations:
Full blood count - Hb 92 g/l, platelet 432 109/L, TWBC 33.2 109/L, lymphocyte 7.5%, neutrophil 84.8%

BUSE and cretinine is are normal, PT was 17.2 sec. ESR 87mm/hr.
LFT - albumin 25g/L, globulin 47g/L, ALP 507u/L
Chest X-ray shows both lower zones has diffuse opacities.

Diagnosis made by the doctors were Melioidosis.
Plan for the patient was to do ultrasound abdoment to rule out liver abcesses, and also I&D for the chest abscess.

I&D was not done on the next day, and was postponed. Patient is on insulin and oral antibiotics. Patient complaint of severe pain and breathlessness that night.

On the following day, patient passed away due to septic shock with ARDS.

Meliodosis:
An infectious disease caused by Burkholderia pseudomallei. A Fulminant and fatal disease.
Predisposing factors includes diabetes mellitus, chronic renal failure, retroviral infection, long term steroind therapy, alcoholism etc.

Clinical features
- incubation period may range from 2 days to many years.
  1. Acute localized infection
  2. Pulmonary infection - range from mild bronchitis to severe fulminant pneumonia.
  3. acute septicaemia
  4. Chronic suppurative infection - typically involves joints, viscera, skin, brain, lung, bone etc etc.
Diagnosis:
  • the key tp diagnosis lies in a constant reminder of the existence of the disease.
  • Culturing of Burkholderia pseudomallei from blood, urine, sputum, pus, tissue biopsies can be done, it is gold standard in diagnosis.
  • Serological tests.
Treatment:
  • antibiotic therapy. Usually sensitive to doxycycline, ceftazidime, ciprofloxacin. Treatment should be started promptly.