A Rare Case of Melioidosis Causing Multifocal Osteomyelitis in an Uncontrolled Diabetic Host

INTRODUCTION: Melioidosis caused by Gram-negative bacterium Burkholderia pseudomallei. It usually causes abscesses in lung, liver, spleen, skeletal muscle, and parotids in patient with risk factors such as diabetes mellitus, heavy alcohol use, smoking, chronic lung disease, and corticosteroid use. Musculoskeletal melioidosis is not common in India even though sporadic cases have been reported mostly involving soft tissues. CASE REPORT: A 45-year-old gentleman, farmer by occupation, belong to state of TamilNadu, type 1 diabetes mellitus with poor glycemic control, presented to us with complaints of multiple joint spain which includes severe pain over left elbow followed by mild pain over bilateral knee and right ankle for past 3 months and on and off fever for past 10 days. Clinically, patient was toxic (shows features of infection). On further investigation (Magnetic resonance imaging and X-ray left elbow, bilateral knee, and right ankle), it was found to be consistent with multifocal osteomyelitis. On arthrotomy and surgical debridement of the left elbow joint followed by intra-operative pus culture shows Staphylococcus aureus growth and patient was started on intravenous cefoperazone-sulbactam 1.5 g for 2 weeks, following which symptoms reappear. 2-d echo was done to rule out infective endocarditis. Technetium 99-methyl diphosphonate (MDP) whole-body scintigraphy shows increase uptake in the left elbow, bilateral knee, and right ankle. Now heunderwent bilateral knee and right ankle arthrotomy and surgical debridement. Polymerase chain reaction for melioidosis was positive. Gram-stain shows growth of B.pseudomallei. Serial blood cultures grew Gram-negative bacilli, later identified as B. pseudomallei, and diagnosed to have melioidosis, following which he was started on injection ceftazidime 2 g TDS (Q8 hourly) for 4 weeks followed by oral cotrimoxazole for next 6 months. The patient was followed up for a period of 2 years (1, 3, 6, and 12 months) and he was found to be recovered completely with no recurrences.. CONCLUSION: Diagnosis of melioidosis missed in many parts of the world due to lack of awareness of this infection caused by B.pseudomallei. Delay in diagnosis or treatment against melioidosis can worsen the outcome. Initial therapy with intravenous antibiotics followed by oral maintenance therapy and appropriate surgical intervention remains vital in the management.