A traveller presenting with severe melioidosis complicated by a pericardial effusion: a case report
Schultze et al. BMC Infectious Diseases 2012, 12:242http://www.biomedcentral.com/1471-2334/12/242
A traveller presenting with severe melioidosiscomplicated by a pericardial effusion: a casereport
Detlev Schultze1*, Brigitt Müller2, Thomas Bruderer1, Günter Dollenmaier1, Julia M Riehm3 and Katia Boggian4
Background: Burkholderia pseudomallei, the etiologic agent of melioidosis, is endemic to tropic regions, mainly inSoutheast Asia and northern Australia. Melioidosis occurs only sporadically in travellers returning fromdisease-endemic areas. Severe clinical disease is seen mostly in patients with alteration of immune status. Inparticular, pericardial effusion occurs in 1-3% of patients with melioidosis, confined to endemic regions. To our bestknowledge, this is the first reported case of melioidosis in a traveller complicated by a hemodynamically significantpericardial effusion without predisposing disease.
Case presentation: A 44-year-old Caucasian man developed pneumonia, with bilateral pleural effusions andcomplicated by a hemodynamically significant pericardial effusion, soon after his return from Thailand toSwitzerland. Cultures from different specimens including blood cultures turned out negative. Diagnosis was onlyaccomplished by isolation of Burkholderia pseudomallei from the pericardial aspirate, thus finally enabling theadequate antibiotic treatment.
Conclusions: Melioidosis is a great mimicker and physicians in non-endemic countries should be aware of itsvaried manifestations. In particular, melioidosis should be considered in differential diagnosis of pericardial effusionin travellers , even without risk factors predisposing to severe disease.
Keywords: Melioidosis, Burkholderia pseudomallei, Pericardial effusion, Traveller
from December 2008 until February 2009. The general
Melioidosis is a great mimicker and on clinical grounds it
practitioner treated the patient for community-acquired
is often impossible to differentiate it from other acute and
pneumonia with amoxicillin-clavulanate for seven days.
chronic bacterial infections. Definite diagnosis relies on
After initial improvement, the patient became febrile and
isolation and identification of its causative agent, Burkhol-
deria pseudomallei . In different endemic regions,
On admission the patient was febrile (38.3°C), had a
pericardial effusion occurs in 1-3% of patients with meli-
tachycardia of 130 beats/minute, a blood pressure of
oidosis . We present a case of severe melioidosis with a
120/78 mmHg, and a respiratory rate of 40/min.
hemodynamically significant pericardial effusion in a trav-
Although the patient showed jugular venous disten-
eller returning to a non-endemic region.
tion, neither Kussmaul’s sign nor hepatomegaly or per-ipheral oedema were observed.
Laboratory tests revealed anaemia (hemoglobin 125 g/l,
A 44-year-old Caucasian man from Switzerland devel-
hematocrit 0.37), leucocytosis, (16.6 G/l; 80% neutrophils,
oped fever and productive cough, two weeks after return-
12% lymphocytes), elevated C-reactive protein (141 mg/l)
ing from north-eastern Thailand, were he had stayed
and elevated B-type natriuretic peptide (208 ng/l). Labora-tory screening for autoimmune diseases and vasculitis was
negative. Electrocardiogram showed sinus tachycardia and
1Center of Laboratory Medicine, Frohbergstrasse 3, CH-9001 St. Gallen,
SwitzerlandFull list of author information is available at the end of the article
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Schultze et al. BMC Infectious Diseases 2012, 12:242
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A chest radiograph showed bilateral pleural effusions
Kit and a PRISM 3130 Genetic Analyzer (Applied
and an enlarged cardiac silhouette. Computed tomog-
Biosystems, Foster City, CA, USA) with sequence ana-
raphy (CT) of the chest confirmed bilateral pleural effu-
lysis by MicroSeq ID Microbial Identification Software
sions, with atelectasis of the inferior lobes, mediastinal
(Applied Biosystems, Foster City, CA, USA) confirmed
lymphadenopathy and a prominent pericardial effusion.
the isolate as B. pseudomallei (DQ108392, 481-bp con-
Abdominal CT showed a small intra-abdominal fluid
sensus length). Multilocus sequence typing (MLST)
of the isolate revealed the allelic profile 1/1/4/1/5/4/1,
Echocardiography confirmed a hemodynamic relevant
corresponding to B. pseudomallei sequence type 207,
pericardial effusion with diastolic compression of the
which has first been isolated from a patient in Thailand
right ventricle and a leftventricular ejection fraction of
with invasive melioidosis in 2001 The isolate was
55%. After pericardiocentesis and aspiration of 700 ml of
sensitive to amoxicillin-clavulanate (2 μg/mL), ceftazidime
a clear yellowish fluid the right ventricular function nor-
(1.5 μg/mL), doxycycline (3 μg/mL) and trimethoprim-
malized, the leftventricular ejection fraction raised to
65%, and the QRS voltage normalized.
testing was carried out by Etest (AB BIODISK, Sweden)
Pleural effusion (1.07 G/l leucocytes, 33% monocytes/
and interpreted according to guidelines established by
nuclear neutrophil leucocytes; LDH 144 U/l with normal
The patient received ceftazidime 2 g every 6 hours for 2
range of LDH in serum <265 U/l ,and with a pleural
weeks followed by maintenance treatment for three
fluid/serum-quotient of 0.4 for LDH and 0.4 for total
months with doxycycline, trimethoprim-sulfamethoxazole
protein, respectively) was negative on Gram- and Ziehl-
and leucovorine. The patient fully recovered after four
Neelsen stains and negative by Polymerase Chain Reac-
months and suffered no relapse in the two years follow-up.
tion Assay for Mycobacterium tuberculosis complex. Cultures remained negative for bacteria, including myco-
bacteria and fungi. Cultures of two sputum samples
Our patient developed signs of respiratory illness within
from the same day yielded normal upper respiratory
the usual incubation period for melioidosis of 1-21 days,
tract flora. Four sets of blood cultures taken on four
shortly after leaving northeastern Thailand, an endemic
consecutive days remained sterile and urine was negative
region for this illness. As Switzerland is not among those
countries, where autochthonous cases of melioidosis
Pericardial effusion (1.4 G/l leucocytes, 58% monocytes/
have been reported the patient probably acquired
macrophages, 23% lymphocytes, 19% polymorphonuclear
the infection during his stay in Thailand.
neutrophil leucocytes; pericardial fluid/serum-quotient of
Pneumonia results from haematogenous spread of
0.6 for total protein content and of 2.3 for LDH activity,
B. pseudomallei to the lung following inoculation through
respectively) was negative on Ziehl-Neelsen stain and
exposure to muddy soils or surface water or alternatively
mycobacterial cultures remained negative. Two blood
by inhalation, as the two main modes of infection [.
culture sets were inoculated with pericardial aspirate
Although melioidosis occurs in all age groups, severe
(10 ml volume per bottle), and a Gram-negative bacillus
clinical disease, such as septicaemic pneumonia, is seen
was isolated from both aerobic bottles after 35 hours
mostly in patients with alteration of immune status, e.g.
diabetes, chronic renal failure or alcoholism Our pa-
(Becton Dickinson AG, Allschwil, Switzerland).
tient had neither a clinical risk factor for melioidosis nor
Although identified as Burkholderia cepacia in a UNMIC/
ID-62 panel of the Phoenix Automated Microbiology
Epidemiologic considerations are very important in
System (Becton Dickinson AG, Allschwil, Switzerland),
the management of pericardial effusion, as in devel-
diagnosis was regarded as tentative, since identification
oped countries acute idiopathic pericarditis and idio-
of B. cepacia by common automated identification
pathic pericardial effusion are the most common
instruments should be confirmed by molecular tests
etiologies, whereas in some underdeveloped geographic
]. Furthermore, pericardial effusion is an unusual
areas tuberculous pericarditis is the leading cause of
location for occurrence of B. cepacia and the isolate
pericardial effusion In a systematic analysis of 106
was unexpectedly sensitive to amoxicillin-clavulanate
pericardial fluid samples from France, a non-endemic
country for melioidosis, B. pseudomallei was not
20NE biochemical test panel V7.0 (bioMérieux, Geneva,
among the detected bacterial agents [Even in en-
Switzerland) yielded Burkholderia pseudomallei (profile
demic regions, pericardial effusion caused by B. pseu-
1156577; 99.9%, ID, 1.0 T). Amplification and sequen-
domallei is a rare phenomenon. In the Darwin
cing of a 500-bp fragment of the 16S rRNA gene by
prospective melioidosis study from tropical Australia
Fast MicroSeq 500 16S rDNA Bacterial Identification
only four of 540 documented cases had pericarditis,
Schultze et al. BMC Infectious Diseases 2012, 12:242
http://www.biomedcentral.com/1471-2334/12/242
three of them with pulmonary infection In a
consent is available for review by the Editor-in-Chief of
10-years retrospective study from Thailand only 12
domestic cases of melioidosis complicated by culture-confirmed pericarditis were found. One-third of these
patients had underlying diseases and two-third showed
The authors declare that they have no competing interests.
evidence of bacteremia with secondary seeding in thepericardium In areas where tuberculosis and
Authors’ contributionsDS supervised the microbiological analyses and wrote the manuscript. ThB,
melioidosis are endemic, complicating pericarditis may
GD, JMR supervised the microbiological analyses and helped to draft the
only be differentiated by pericardial fluid culture and
manuscript. BM and KB contributed to diagnosis and treatment and KB
helped to draft the manuscript and did outpatient follow-up. All authorsread and approved the final manuscript.
As bacteremia could not be detected in our patient,
B. pseudomallei might have gained access into the pericar-
dium through the mediastinal lymph nodes in the course
We are grateful to the patient for permission to publish this case report. The
of pneumonia, known from patients with tuberculosis
Center of Laboratory Medicine, St. Gallen, Switzerland and the BundeswehrInstitute of Microbiology, Munich, Germany funded the microbiological
[]. Cultures from different specimens remained negative
analyses of the samples as part of the quality improvement program. No
for B. pseudomallei. Only culture of pericardial fluid grew
other, especially no commercial funding was received for the study.
the causative agent, possibly due to the use of blood cul-
ture bottles as primary culture medium. Blood culture
1Center of Laboratory Medicine, Frohbergstrasse 3, CH-9001 St. Gallen,
bottles are superior in performance to traditional plated-
Switzerland. 2Department of Internal Medicine, Cantonal Hospital,
medium methods for detection of microorganisms from
Rorschacherstrasse 95, CH-9007 St Gallen, Switzerland. 3Bundeswehr Instituteof Microbiology, Neuherbergstr 11, D-80937 Munich, Germany. 4Department
sterile body fluids Detection of B. pseudomallei from
of Internal Medicine, Division of Infectious Diseases, Cantonal Hospital,
nonsterile specimens such as sputum samples, can be
Rorschacherstrasse 95, CH-9007 St Gallen, Switzerland.
hampered by the overgrowth and masking of B. pseudo-
Received: 4 March 2012 Accepted: 1 October 2012
mallei by commensal flora, if selective culture media are
not used, that are more common in medical laboratoriessituated in countries where the disease is endemic .
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