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| CASE REPORT |
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| Year : 2017 | Volume
: 3
| Issue : 1 | Page : 51-53 |
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Melioidosis mimicking cold abscess
Sherly Antony1, Desdemona Rasitha1, Nirmal P Kumar2, Sheela Devi Chandrakesan1
1 Department of Microbiology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
2 Department of General Surgery, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
| Date of Submission | 01-Mar-2017 |
| Date of Acceptance | 06-Mar-2017 |
| Date of Web Publication | 12-Jul-2017 |
Correspondence Address:
Sheela Devi Chandrakesan
Department of Microbiology, Pondicherry Institute of Medical Sciences, Kalapet - 605 014, Puducherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrsm.jcrsm_3_17
Melioidosis is an infectious disease with varied clinical manifestations. Majority of its symptoms mimic tuberculosis. We report a case of a 19-year-old girl who presented with a swelling on the anterior aspect of her neck of 2 months' duration. It was provisionally diagnosed as cold abscess with fine-needle aspiration cytology done for confirmation. Burkholderia pseudomallei was isolated from the aspirate. The isolate was sensitive to ceftazidime, imipenem, meropenem, and cotrimoxazole. Ultrasound did not reveal any similar lesions elsewhere in the body. Treatment was instituted with intravenous injection of 2 g ceftazidime 6th hourly. The abscess was incised and drained. After completion of intensive phase for 2 weeks, treatment was switched to maintenance phase with cotrimoxazole three tablets for every 12 hours. High level of clinical and microbiological suspicion is important to detect and treat melioidosis in nonendemic areas. Patient's compliance to long-term medications is required which makes treatment a challenge. Keywords: Burkholderia pseudomallei, melioidosis, neck abscess
How to cite this article:
Antony S, Rasitha D, Kumar NP, Chandrakesan SD. Melioidosis mimicking cold abscess. J Curr Res Sci Med 2017;3:51-3 |
| Introduction | |  |
Burkholderia pseudomallei is the causative agent of melioidosis. Melioidosis is often known as “the great masquerader” due to its extremely variable clinical manifestations. This hampers early diagnosis and initiation of appropriate antibiotic therapy. Melioidosis is endemic in many parts of South-East Asia and Australia. Increase in the number of cases from South India has been reported in the recent years.[1] A case of swelling on the neck is reported here due to the necessity of distinguishing it from cold abscess, where treatment modalities are entirely different.
| Case Report | | |
A 19-year-old girl presented to the outpatient department with complaints of swelling on the anterior aspect of the neck of 2 months' duration. It had an insidious onset, with gradual increase in size over the past 2 months without pain. There was a history of intermittent, low-grade fever more pronounced in the evening. She had a history of weight loss of 5 kg over the preceding month along with chronic cough. There was no loss of appetite. She was not a known diabetic and has had no history of contact with tuberculous patients.
A single, nontender swelling of about 3 cm × 4 cm was noted over the center of the neck extending to the right lateral border of the sternocleidomastoid muscle. It did not move with deglutition or with protrusion of tongue. The swelling was firm in consistency with a smooth surface. There was no local rise of temperature over the swelling. There were no dilated veins, scars, or sinuses seen over the neck. There were multiple enlarged cervical lymph nodes. Her weight was 33 kg. Laboratory investigations showed an elevated erythrocyte sedimentation rate (50 mm/h), total counts of 9.9 μl × 1000 μl with predominance of neutrophils (84%). Her random blood sugar was 84 mg/dl. Ultrasonogram of the neck showed heterogeneous subcutaneous collection in the paramedian region approximately 4 cm × 5 cm with necrotic cervical nodes.
A provisional diagnosis of cold abscess of the neck was made. Fine-needle aspiration cytology did not reveal any granuloma suggestive of tuberculosis. Gram stain from pus revealed plenty of polymorphs with short Gram-negative bacilli. The specimen was processed according to standard microbiological procedures. After overnight incubation, characteristic dry wrinkled pink colonies were observed on MacConkey agar. [Figure 1]. These were Gram-negative bacilli with bipolar staining [Figure 2]. The isolate was confirmed as B. pseudomallei by Vitek 2 compact automated system. The isolate was sensitive to ceftazidime, cotrimoxazole, imipenem, and meropenem. It was resistant to aminoglycosides and polymyxin-B. She was started on ceftazidime 2 g intravenous 6th hourly. Ultrasonography abdomen was done to rule out visceral abscesses. The swelling was incised and drained. The pus also grew B. pseudomallei. She was discharged and advised to follow up with the maintenance-phase therapy of cotrimoxazole three tablets twice daily for 3 months. | Figure 1: Characteristic pink, dry wrinkled colonies of Burkholderia pseudomallei on MacConkey agar
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 | Figure 2: Gram-stained colony smear (×1000 magnification) showing Gram-negative bacilli with bipolar appearance
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| Discussion | | |
Tuberculosis is endemic in India.[2] A case of painless swelling on the neck generally prompts a diagnosis of tuberculous cold abscess.
Melioidosis is endemic in North Australia and South-East Asian regions of Thailand, Singapore, Malaysia, Myanmar, and Vietnam.[3] There are increased reports from India, especially in the southern parts, perhaps due to increased awareness among clinicians and efforts by microbiologists to isolate and identify this organism in the laboratory.[4],[5],[6],[7]
B. pseudomallei is found commonly in soil. The mode of transmission of infection is mainly through either inhalation or inoculation. The most common risk factors are diabetes, chronic alcoholism, and immunosuppressed conditions such as chronic renal, liver or lung disease. Studies have shown that soil is the niche for this organism.[3],[8] The patient hailed from a village in Tamil Nadu and had a history of her house being located in the center of a field which had been recently ploughed. The area had abundant rainfall 4 months back. Soil exposure may have been the risk factor in this case.
Clinical symptoms vary from acute to chronic manifestations. It can affect any organ, primarily lung, liver, spleen, skin, lymph nodes, bones, joints, brain, and heart. Few reports of abscesses at unusual sites such as neck, adrenals, and chest wall have been quoted in the literature.[9]
From Puducherry, Vishnu Prasad et al. in 2012 reported a case of melioidosis causing anterior chest wall abscess resembling cold abscess of tuberculosis.[10] Vidyalakshmi et al. in 2008 reported one case of lymphadenitis initially diagnosed as tuberculosis but later identified as melioidosis. The study also reported 22 different cases with varied presentations, all mimicking tuberculosis but proved otherwise.[2] Chandrakar and Dias reported a case of neck abscess in a cluster of 28 culture-confirmed cases of B. pseudomallei from Mangalore between 2012 and 2014.[7] The largest report of melioidosis (95 cases) from India included seven cases of lymphadenopathy, of which four cases were of cervical lymphadenopathy resembling tuberculosis.[6]
A high index of suspicion is required to diagnose melioidosis in areas endemic for tuberculosis, as the management of both these conditions differs greatly. Initiating anti-tubercular therapy versus specific antibiotics in melioidosis is also a challenge in the absence of laboratory confirmation. Incision and drainage is contraindicated in tuberculosis while being crucial for other bacterial etiologies, including melioidosis.
Acknowledgments
We acknowledge Dr. Reba Kanungo, Professor and Head of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry, India, for her technical input and writing the manuscript. We also acknowledge Dr. Anusha Rohit, Consultant Microbiologist, Madras Medical Mission, Chennai, for confirming the identity of the organism.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 7. | Chandrakar S, Dias M. Clinico-epidemiological spectrum of melioidosis: A 2-year prospective study in the Western coastal region of India. S Afr J Infect Dis 2016;31:14-9. |
| 8. | Prakash A, Thavaselvam D, Kumar A, Kumar A, Arora S, Tiwari S, et al. Isolation, identification and characterization of Burkholderia pseudomallei from soil of coastal region of India. Springerplus 2014;3:438. |
| 9. | Limmathurotsakul D, Peacock SJ. Melioidosis: A clinical overview. Br Med Bull 2011;99:125-39. |
| 10. | Vishnu Prasad NR, Balasubramaniam G, Karthikeyan VS, Ramesh CK, Srinivasan K. Melioidosis of chest wall masquerading as a tubercular cold abscess. J Surg Tech Case Rep 2012;4:115-7. |
[Figure 1], [Figure 2]
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