|Year : 2020 | Volume
| Issue : 3 | Page : 192-193
Cutaneous melioidosis in a healthy young man
Sheng-Wen Liu1, Chien-Ping Chiang1, Wei-Ming Wang2, Chih-Tsung Hung2
1 Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
2 Department of Dermatology, Tri-Service General Hospital; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
|Date of Submission||01-Jan-2020|
|Date of Decision||22-Feb-2020|
|Date of Acceptance||22-Mar-2020|
|Date of Web Publication||16-Jun-2020|
Dr. Chih-Tsung Hung
Department of Dermatology, Tri-Service General Hospital, No. 325, Sec. 2, Chenggong Road, Neihu District, Taipei City 114
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Liu SW, Chiang CP, Wang WM, Hung CT. Cutaneous melioidosis in a healthy young man. Dermatol Sin 2020;38:192-3
Melioidosis is an infectious disease caused by Burkholderia pseudomallei, a Gram-negative environmental bacterium endemic to soils of tropical areas, most prevalently in Northern Australia and Southeast Asia. Melioidosis has protean clinical manifestations with varying severity. Primary skin infection is an uncommon presentation of melioidosis cases. Herein, we report a case of cutaneous melioidosis in a healthy young man.
A 20-year-old Taiwanese male who had been robust in the past presented to our outpatient clinic with 1-month history of a tender 2 cm × 2 cm nodule on his right elbow. He was afebrile and had no other symptoms. He denied travel history to other countries but recalled soil contact during military training in Southern Taiwan before the appearance of the skin lesions. He stated that the lesions gradually progressed despite taking amoxicillin prescribed from local medical clinic. Physical examination showed an erythematous indurated nodule with crusted ulceration at the center [Figure 1]. Neither lymphadenopathy nor other significant findings were noticed. Wound discharge was sent for bacterial culture, which yielded typical wrinkled colonies of B. pseudomallei [Figure 2]a and [Figure 2]b, establishing the diagnosis of melioidosis. Laboratory investigations on admission showed white blood cell count of 6.07 × 103/mL and slightly elevated alanine aminotransferase of 49 U/L. Serum urea and creatinine were within normal limits. Two sets of blood cultures were negative, and chest X-ray was normal. The patient was treated with ceftazidime 2 g three times daily and doxycycline 100 mg two times daily for a week, followed by oral trimethoprim-sulfamethoxazole (TMP-SMX) 80/400 mg two times daily and doxycycline 100 mg two times daily for 12 weeks. The lesion healed completely.
|Figure 1: The patient presented with an erythematous indurated nodule with crusted ulceration at the center|
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|Figure 2: Bacterial culture of wound discharge grew coliform-like wrinkled colonies on MacConkey agar (a) and blood agar (b)|
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Melioidosis occurs mainly in those with exposure to soil or water contaminated with B. pseudomallei in endemic areas. Transmission modes include inhalation, percutaneous inoculation, and to a lesser extent, ingestion of contaminated food or water.
Among the 516 melioidosis cases reported in Taiwan from 2000 to 2017, about 86% were geographically distributed south of the Tropic of Cancer in Taiwan. In addition, over 50% of these cases were successively clustered in certain areas. The vast majority of cases occurred in rainy seasons or after typhoons strikes and acute pulmonary presentation far outnumbered other forms of melioidosis, which can be explained by the fact that inhalation of aerosols often follows heavy rainfall or typhoons and is associated with higher risks of pneumonic presentation and bacteremia. However, melioidosis with localized infection can occur in dry seasons.
Our patient recalled soil contact during military training on the ground in Fengshan, Kaohsiung, before the appearance of the skin lesions. During that time, there had been neither typhoon attacks nor heavy rains. We speculated that direct inoculation of B. pseudomallei via an unnoticed open wound resulted in his localized infection.
A prospective study in Australia found that compared with those with other forms of melioidosis, patients with primary cutaneous manifestation were younger, were more likely to present during the dry seasons, and had better outcomes. In addition, known risk factors of melioidosis, including diabetes, alcoholism, chronic lung, or kidney disease, were all less commonly associated with primary cutaneous melioidosis than with other melioidosis.
Culture remains the gold standard for diagnosis of melioidosis and is 100% specific. Isolation of B. pseudomallei from any body site establishes definitive diagnosis of melioidosis.B. pseudomallei colonies have typical wrinkled morphology on both blood agar and MacConkey agar and appeared cream-colored on blood agar and pink on MacConkey agar.
Because melioidosis has a protracted course and frequently relapses, its treatment should encompass an intensive phase of intravenous ceftazidime, meropenem, or imipenem for at least 10 days and an eradication therapy of oral TMP-SMX for 3–6 months. TMP-SMX in combination with doxycycline has been used for eradication phase in some countries and was deemed as the treatment guideline by the Center for Disease Control in Taiwan. Considering that our patient had only uncomplicated localized skin infection, we gave eradication therapy for a week, followed by the combined use of TMP-SMX and doxycycline for 12 weeks as eradication therapy. The skin lesions healed well without recurrence.
Our case demonstrates that the differential diagnosis should include cutaneous melioidosis for a prolonged nonhealing ulcer despite multiple courses of antibiotics in patients with history of soil contact in endemic areas. Culture remains the gold standard for diagnosis. B. pseudomallei colonies typically appear wrinkled and coliform-like in morphology. Instant awareness followed by accurate diagnosis as well as prompt prescription of adequate antimicrobial agents is the key to successful treatment of melioidosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]