Melioidosis 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.
We thank the National Microbiology Laboratory for confirming the identification of the B. pseudomallei isolate and performing molecular testing and antimicrobial susceptibility testing.
(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)
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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|Author:||Hogan, Catherine; Wilmer, Amanda; Badawi, Mazen; Hoang, Linda; Chapman, Michael; Press, Natasha; Ant|
|Publication:||Emerging Infectious Diseases|
|Article Type:||Letter to the editor|
|Date:||May 1, 2015|
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