Melioidosis

An 8-year-old boy was brought with a history of high-grade fever for 2 weeks. In the first week of fever, he had vomiting and mild epigastric pain. He had been evaluated elsewhere and the blood reports revealed mild anemia, elevated C-reactive protein (CRP), normal total and differential leucocyte counts, and a normal platelet count. He had been treated for “typhoid fever” with oral cefixime for 1 week, but no blood culture reports were available. As high-grade fever continued, he was referred to our hospital. Vomiting had stopped but mild, intermittent abdominal pain continued. There was no history of any diarrhea, constipation, jaundice, rash, joint pain, or any other localizing symptoms. There was no history of contact with tuberculosis or consumption of unpasteurized milk. He had been immunized according to the national immunization schedule till 5 years of age. On examination, he was underweight but well preserved. His vital signs were normal and he had pallor. There were no significant lymph nodes, rashes, or jaundice. Palpation of the abdomen revealed a tender hepatomegaly of 3 cm and a soft tender spleen. A clinical diagnosis of partially treated enteric fever was made. He was hospitalized and investigations revealed hypochromic microcytic anemia (Hb 7.9 g%), raised CRP level (214.1 mg/L), polymorphonuclear leukocytosis (total leucocyte count was 17,890/cu mm with 70% neutrophils), and an ESR of 32 mm first hour. He was started on intravenous (IV) antibiotics. USG abdomen was done, and it showed an ill-defined hetero-echoic focal lesion in the right lobe of the liver and an ill-defined hetero-echoic focal collection in the lower pole of the spleen. A contrast-enhanced CT scan of the abdomen also was carried out as per the radiologist advice for better characterization. Both the abscesses were aspirated under USG guidance. The purulent material obtained was sent for microbiological investigations. The pus culture was reported as Burkholderia pseudomallei. The child was started on intravenous ceftazidime, and percutaneous pigtail catheters were inserted into both the abscess cavities for drainage. IV ceftazidime was given for a total period of 14 days after which he was discharged on oral trimethoprim–sulfamethoxazole for 3 months. Repeat ultrasound after 3 months showed complete resolution of the abscesses. On follow-up, he remained asymptomatic.