Melioidosis in a Resident of Texas with No Recent Travel History, United States

Abstract

B urkholderia pseudomallei, which causes melioidosis, is a gram-negative saprophytic bacterium endemic to tropical and subtropical environments worldwide; to our knowledge, isolation from the continental United States has not been reported (1-3). The most overrepresented risk factor for melioidosis is diabetes mellitus (3,4). B. pseudomallei is resistant to many antimicrobial drugs (3). Laboratory exposures might occur without appropriate biosafety precautions (2,5). Surveillance is challenging because melioidosis is not nationally notifiable; however, B. pseudomallei is a Tier 1 overlap Select Agent (6), and the Centers for Disease Control and Prevention (CDC) receives voluntary reports (2,7). We report a case of melioidosis in a Texas resident who had no recent travel history. The Study On November 17, 2018, a 63-year-old man from Atascosa County, Texas, came to hospital A with fever, chest pain, and dyspnea of 3 days' duration. At admission, he reported congenital unilateral renal agenesis. Renal function measures were unremarkable. Increased hemoglobin A1c level and hyperglycemia (glucose >200 mg/dL) suggested undiagnosed type 2 diabetes. Computed tomography of chest and abdomen with intravenous contrast showed left lower lobe pneumonia with a small left pleural effusion. Empiric antimicrobial drug therapy with intravenous azithromycin and ceftriaxone was initiated. Blood culture yielded presumptive B. pseudomallei, which was sent for confirmation to the laboratory response network (LRN) site in Houston, Texas. On November 20, a localized, violaceous, cutaneous lesion developed on the central anterior chest wall of the patient and progressed to become purulent and ulcerated (Figure 1). The next day, he experienced respiratory failure, was emergently intubated, and was transferred to hospital B. Hospital B was not aware of the presumptive diagnosis and performed a blood and chest wound culture. Both cultures showed gram-negative rods; blood analysis showed acute kidney injury. On November 25, B. pseudomallei susceptible to trimethoprim/sulfamethoxazole and ceftazidime (Table) was identified, and treatment was switched to ceftazidime by using dosing for continuous renal replacement therapy (4). On November 26, the patient was extubated and began hemodialysis (3 ×/wk). He was discharged on December 9 and received 3 months of daily trimethoprim/sulfamethoxazole (4). Subsequent followup showed clinically recovery and resolution of z renal insufficiency.

Epidemiological and Clinical Characteristics of Melioidosis Caused by Gentamicin-SusceptibleBurkholderia pseudomalleiin Sarawak, Malaysia

“…This is similar to recent studies from Laos and Myanmar [ 25 , 26 ], which suggest a dynamic process of more recent possibly anthropogenically driven regional dispersal of Bp, in addition to the ancient intercontinental dispersals originally from Australia, where Bp is thought to have arisen [ 12 ]. The spread of Bp in the Americas is considered a more recent phenomenon, with recent evidence suggesting that Bp may now be endemic in the United States [ 4 ].…”

“…Melioidosis is an important cause of infectious disease mortality in the Western Pacific region and in Southeast Asia (SEA) [ 1 , 2 ]. Although historically known to be endemic to SEA and northern Australia, cases are now increasingly being reported worldwide [ 3 , 4 ]. Melioidosis is caused by the environmental saprophyte Burkholderia pseudomallei ( Bp ), a gram-negative bacillus that is intrinsically resistant to a broad range of antibiotics, including aminoglycosides [ 5 ].…”

Myanmar Burkholderia pseudomallei strains are genetically diverse and originate from Asia with phylogenetic evidence of reintroductions from neighbouring countries

“…Prior studies have shown that B. pseudomallei originally evolved in the environment of Australia and subsequently spread to Southeast Asia and East Asia during the last glacial period (between 16 and 225 thousand years ago) 12 . From Asia, B. pseudomallei subsequently spread to Madagascar and Africa and more recently from West Africa to the Americas (between 1650 and 1850), likely linked to the slave trade 12 – 15 . This strong geographic signal of the B. pseudomallei genome is notably due to infection in humans and animals being acquired directly from an environmental source, with human–human and zoonotic transmission being exceedingly rare.…”

Multinucleated Giant Cell Formation as a Portal to Chronic Bacterial Infections

“…However, increasing surveillance and diagnostic capabilities have revealed that Bpm is also found in the soil in the Middle East, sub-Saharan Africa, the Caribbean islands, and the Americas [ 1 ]. Recently, a non-travel related case of melioidosis was identified in Texas and, together with another prior case in the same area, suggest that Bpm might be present in the soil of the continental United States [ 2 ]. It has been estimated that there are 165,000 cases of melioidosis a year with 89,000 deaths globally [ 1 ].…”