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Melioidosis in Trinidad and Tobago.

To the Editor: Melioidosis refers to infection caused by the facultative intracellular gram-negative bacterium Burkholderia pseudomallei. The clinical manifestations of melioidosis span a wide spectrum, from asymptomatic exposure or localized cutaneous infection to septic shock with multi-organ failure. Melioidosis usually occurs in residents of or travelers to disease-endemic areas in northern Australia and Southeast Asia; however, an increasing number of confirmed melioidosis cases are being reported from the Caribbean. We report a case of melioidosis acquired in Trinidad and Tobago.

In February 2014, a 17-year-old male student was admitted to a tertiary care hospital in Vancouver, British Columbia, Canada, with catecholaminergic polymorphic ventricular tachycardia and electrical storm. He had a 9-month history of dry cough that was unresponsive to multiple and prolonged courses of treatment for community-acquired pneumonia. During the 6 months before his admission, the patient had hemoptysis and radiologic evidence of pneumonia that were treated with courses of cephalosporins without resolution of symptoms. Bronchoscopy and culture of lavage samples had revealed infection with Staphylococcus aureus and an organism most closely related to Actinomyces graevenitzii.

The patient had no history indicative of risk factors for recurrent sinusitis or pneumonia (e.g., cystic fibrosis, chronic granulatomous disease, Job syndrome), and no risk factors for tuberculosis or infection with dimorphic fungi. He was up to date on his vaccinations and had no pets. He was born in Jamaica, had moved to Canada at age 4, and had not traveled anywhere other than Trinidad and Tobago, Canada, and England. He had traveled to visit family in Trinidad for 2 months during the rainy season in 2012, at which time he also visited Tobago.

On day 5 of hospital admission, the patient became febrile (39.6[degrees]C), and an infectious diseases specialist was consulted. Examination revealed that the patient was clinically stable but emaciated at 45 kg. His oxygen saturation while breathing room air was 98%. Physical examination, including cardiorespiratory examination, was unremarkable. Laboratory results showed a normal hemoglobin concentration of 133 g/L; elevated leukocyte count of 22.8 x [10.sup.9] cells/L; neutrophils 19.4 x [10.sup.9] cells/L; normal platelet count of 295 x [10.sup.9]/L; and normal creatinine of 54 [micro]mol/L. Test results for HIV-1 and blood cultures were negative. Computed tomography scan showed dilated bronchi and dense consolidation of the right and left lower lobes. Piperacillin/tazobactam was started for presumed hospital-acquired pneumonia.

The patient underwent diagnostic bronchoscopy with bronchoalveolar lavage. Gram staining of specimens showed occasional gram-negative bacilli, and aerobic cultures grew gram-negative bacilli. Further testing with the Vitek 2 (bioMerieux, Laval, Quebec, Canada) (96%) and RapID NF (Oxoid, Nepean, Ontario, Canada) (99.9%) systems identified B. pseudomallei, but matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (Vitek MS, bioMerieux) did not. Phenotypic confirmation was performed at the provincial public health and reference laboratory. Antimicrobial drug susceptibility testing performed by broth microdilution according to Clinical and Laboratory Standards Institute recommendations (1) and by Etest (bioMerieux) showed susceptibility to amoxicillin/clavulanic acid, ceftazidime, imipenem, doxycycline, and trimethoprim/sulfamethoxazole. The patient's condition improved after 2 weeks of intravenous meropenem, and antimicrobial therapy was changed to oral trimethoprim/sulfamethoxazole.

The B. pseudomallei isolate was sent to the Public Health Agency of Canada's National Microbiology Laboratory for molecular typing. Query of 7 standard multilocus sequence typing loci (http://bpseudomallei.mlst.net/) identified the isolate as a novel multilocus sequence type. The sequence type (1,1,2,1,5,6,1) closely resembled that of B. pseudomallei previously isolated from the Caribbean (2).

Although melioidosis was first described in the Caribbean in 1947 (3), most case reports of the disease in the area are from the past 2 decades. This case report suggests progression of the range of melioidosis to include Trinidad and Tobago. A recent study documented the presence of B. pseudomallei in soil samples and high seroprevalence rates among contacts of persons with melioidosis in Puerto Rico (4). If examined, this pattern of regional melioidosis endemicity may also be found on other Caribbean islands.

Increased clinical awareness of and improved surveillance for B. pseudomallei infection may partly explain emergence. Nonetheless, underascertainment probably occurs in rural areas with limited access to advanced diagnostic support and in urban areas when B. pseudomallei infection is not suspected because of lack of travel to classic disease-endemic areas. Because B. pseudomallei is a Biosafety Level 3 agent, when infectious disease specialists consider melioidosis in their differential diagnoses, they should alert the microbiology laboratory to confirm species identification and ensure that staff use proper biosafety measures.

A total of 19 cases of melioidosis acquired in the Caribbean have been reported (Table). Nine of these were travel related, suggesting that melioidoisis may be emerging as a travel health issue. Travelers with known risk factors for melioidosis, such as diabetes mellitus and chronic lung disease, should be informed of their increased infection risk. Physicians should include B. pseudomallei in the differential diagnosis of travelers with pneumonia or sepsis who are returning from the Caribbean, particularly when they have a history of travel during the rainy season, soil-contaminated wounds, or known risk factors for melioidosis.

Acknowledgment

We thank the National Microbiology Laboratory for confirming the identification of the B. pseudomallei isolate and performing molecular testing and antimicrobial susceptibility testing.

References

(1.) Clinical and Laboratory Standards Institute. Methods for antimicrobial dilution and disk susceptibility testing of infrequently isolated or fastidious bacteria. CLSI document M45-A2. 2nd ed. Wayne (PA): The Institute; 2010.

(2.) Godoy D, Randle G, Simpson AJ, Aanensen DM, Pitt TL, Kinoshita R, et al. Multilocus sequence typing and evolutionary relationships among the causative agents of melioidosis and glanders, Burkholderia pseudomallei and Burkholderia mallei. J Clin Microbiol. 2003;41:2068-79. http://dx.doi.org/10.1128/ JCM.41.5.2068-2079.2003

(3.) McDowell F, Varney PL. Melioidosis, report of first case from the Western Hemisphere. J Am Med Assoc. 1947;134:361. http://dx.doi.org/10.1001/jama.1947.72880210001008

(4.) Doker TJ, Sharp TM, Rivera-Garcia B, Perez-Padilla J, Benoit TJ, Ellis EM, et al. Contact investigation of melioidosis cases reveals regional endemicity in Puerto Rico. Clin Infect Dis. 2015;60:243-50. http://dx.doi.org/10.1093/cid/ciu764

(5.) Inglis TJ, Rolim DB, Sousa Ade Q. Melioidosis in the Americas. Am J Trop Med Hyg. 2006;75:947-54.

(6.) Corral DM, Coates AL, Yau YC, Tellier R, Glass M, Jones SM, et al. Burkholderia pseudomallei infection in a cystic fibrosis patient from the Caribbean: a case report. Can Respir J. 2008;15:237-9.

(7.) O'Sullivan BP, Torres B, Conidi G, Smole S, Gauthier C, Stauffer KE, et al. Burkholderia pseudomallei infection in a child with cystic fibrosis: acquisition in the Western Hemisphere. Chest. 2011;140:239^2. http://dx.doi.org/10.1378/chest.10-3336

(8.) Meckenstock R, Therby A, Marque-Juillet S, Monnier S, Khau D, Pangon B, et al. Cutaneous melioidosis in adolescent returning from Guadeloupe. Emerg Infect Dis. 2012;18:359-60. http://dx.doi.org/10.3201/eid1802111603

(9.) Getaz L, Abbas M, Loutan L, Schrenzel J, Iten A, Simon F, et al. Fatal acute melioidosis in a tourist returning from Martinique Island, November 2010. Euro Surveill. 2011;16:19758.

(10.) Mickail N, Klein NC, Cunha BA, Schoch PA. Melioidosis breast abscesses. J Infect. 2012;64:434-5. http://dx.doi.org/10.1016/ j.jinf.2011.12.016

Address for correspondence: Melanie Murray, BC Women's Hospital & Health Centre, E600B, 4500 Oak St, Vancouver, BC V6H 3N1, Canada; email: Melanie.Murray@cw.bc.ca

Author affiliations: University of Sherbrooke, Sherbrooke, Quebec, Canada (C. Hogan); University of British Columbia, Vancouver, British Columbia, Canada (A. Wilmer, M. Badawi, L. Hoang, M. Chapman, N. Press, M. Romney, M. Murray); King Abdulaziz University, Jeddah, Saudi Arabia (M. Badawi); British Columbia Centre for Disease Control Public Health Microbiology and Reference Laboratory, Vancouver (L. Hoang); St. Paul's Hospital, Vancouver (N. Press, M. Romney, M. Murray); National Microbiology Laboratory, Winnipeg, Manitoba, Canada (K. Antonation, C. Corbett); British Columbia Women's Hospital, Vancouver (M. Murray)

DOI: http://dx.doi.org/10.3201/eid2105.141610
Table. Published case reports of melioidosis from the Caribbean *

           Site of        Age,      Type of       Concurrent
Ref.    origin (year)    y/sex      exposure       condition

(3)         Panama        31/M      Fall on      Polio, spinal
            (1947)                buttock, TR     meningitis

(5)         Panama        25/F      UNK, TR          None
            (1948)

(5)         Panama        20/M        UNK            None
            (I960)

(5)      Puerto Rico      62/F        UNK          Diabetes,
            (1982)                                   sle,
                                                   cirrhosis

(5)         Mexico        72/M        UNK            None
            (1986)

(5)       Martinique      66/M        unk,         Diabetes
            (1995)                  resident

(5)       Guadeloupe      4/M       UNK, TR          None
            (1997)

(5)      Puerto Rico      11/M        unk,         X-linked
            (1997)                  resident          CGD

(5)      El Salvador      unk       UNK, TR           UNK
            (2001)

(4)      Puerto Rico      55/F    Flood water,     Diabetes
            (2003)                  resident

(6)        British        17/M        unk,            CF
        Virgin Islands              resident
            (2006)

(7)         Aruba         7/F       UNK, TR           CF
            (2009)

(4)      Puerto Rico      88/M       Ditch         CAD, PVD
            (2009)                  digging,
                                    resident

(8)       Guadeloupe      15/F      UNK, TR         Asthma,
            (2010)                               dengue fever

(9)       Martinique      35/M      UNK, TR          None
            (2010)

(10)        Aruba         46/F       Water           None
            (2012)                exposure, TR

(4)      Puerto Rico      38/M    Landscaping,       None
            (2010)                  resident

(4)      Puerto Rico      60/M    Agricultural     Diabetes
            (2012)                   work,
                                    resident

This       Trinidad       17/M       Rainy           CPVT
study     and Tobago               season, TR
            (2014)

            Clinical           Diagnostic
Ref.      manifestation          method

(3)          Buttock        Abscess culture
             abscess

(5)      Retroperitoneal    Abscess culture
         abscess, sepsis

(5)       Acute septic       Synovial fluid
            arthritis           culture

(5)          Septic          Blood and CSF
           meningitis           culture

(5)        Pneumonia,       Blood and sputum
         splenic abscess        culture

(5)          Sepsis         Blood and urine
                                culture

(5)        Pneumonia,        Pleural fluid
        pleural effusion,       culture
           peritonitis

(5)      Mediastinitis,     Supraclavicular
          lymphadenitis     and hilar biopsy
                                culture

(5)         Cerebral              UNK
             abscess

(4)        Pneumonia,       Blood and sputum
          septic shock          culture

(6)         Pneumonia       Sputum culture,
                                  PCR

(7)         Pneumonia        Oropharyngeal
                              and induced
                             sputum culture

(4)         Pneumonia             MLST

(8)        Adenopathy,        Tumefaction
           tumefaction          culture
                                  PCR

(9)         Diarrhea,        Blood culture;
            pneumonia             PCR

(10)         Breast         Abscess culture
            abscesses

(4)        Pneumonia,       Immunohistochem
           hepatitis,          istry with
          myocarditis,       polyclonal Ab;
          septic shock            PCR

(4)         Diabetic         Blood culture;
          ketoacidosis            MLST

This         Chronic          BAL culture;
study       pneumonia             MLST

                Treatment
Ref.           (duration)              Outcome

(3)          Sulfathiazole,            Survived
             sulfapyridine,
        streptomycin, penicillin

(5)     Penicillin, streptomycin         Died

(5)         Chloramphenicol,           Survived
        novobiocin, sulfisoxazole

(5)            Penicillin,               Died
            chloramphenicol,
          moxalactam, amikacin

(5)       Cefoxitin, gentamicin          Died

(5)       IV ceftazidime, then         Survived
            oral TMP/SMX and
           doxycycline (2 mo)

(5)        IV ceftazidime and          Survived
           TMP/SMX(1 mo), then
           oral TMP/SMX (6 mo)

(5)           Imipenem and          Died ([dagger])
         doxycycline (6 weeks),
            oral cefixime and
           doxycycline (3 wk)

(5)                UNK                 Survived

(4)        Imipenum, amikacin,           Died
              azithromycin

(6)                UNK                 Survived

(7)           Imipenem and             Survived
        ceftazidime (14 d), then
            inhaled meropenem
        (28 d) and long-term oral
                 TMP/SMX

(4)       Doxycycline (20 wk),         Survived
              oral TMP/SMX

(8)      IV ceftazidime (10 d),        Survived
            then oral TMP/SMX
                 (12 wk)

(9)             Imipenem,                Died
                  G-CSF

(10)     Meropenem (14 d), then        Survived
          oral TMP/SMX (12 wk)

(4)               None                   Died

(4)      Amoxicillin/cloxacillin       Survived
            (10 d), then oral
           TMP/SMX (12 weeks)

This      Meropenem (2 weeks),         Survived
study       then oral TMP/SMX
             (8 mo to date)

* Ab, antibody; BAL, bronchoalveolar lavage; CAD, coronary artery
disease; CGD, chronic granulomatous disease; CPVT, catecholaminergic
polymorphic ventricular tachycardia; CSF, cerebrospinal fluid; G/CSF,
granulocyte colony/stimulating factor; IV, intravenous; MLST,
multilocus sequence typing; PVD, peripheral vascular disease; Ref.,
reference; SLE, systemic lupus erythematosus; TMP/SMX, trimethoprim/
sulfamethoxazole; TR, travel related; UNK, unknown.

([dagger]) Cause of death unknown.
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Title Annotation:LETTERS
Author:Hogan, Catherine; Wilmer, Amanda; Badawi, Mazen; Hoang, Linda; Chapman, Michael; Press, Natasha; Ant
Publication:Emerging Infectious Diseases
Article Type:Letter to the editor
Geographic Code:1CBRI
Date:May 1, 2015
Words:1883
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