Melioidosis case report of a pediatric patient in Cambodia with extrapulmonary findings of Melioidosis case report of a pediatric patient in Cambodia with extrapulmonary findings of mastoiditis and visceral abscessesmastoiditis and visceral abscesses

Yos Pagnarith MDYos Pagnarith MD

Angkor Hospital for Children (AHC), Siem Reap, Kingdom of CambodiaAngkor Hospital for Children (AHC), Siem Reap, Kingdom of Cambodia

Physical Examination

General: alert but fearful child

Vital signs: T 38.4°C, HR 90, RR 24, BP nl, BW 25kg

ENT: right ear discharge obscuring eardrum

Neck: sub-mandibular lymph nodes, mobile and not painful

Resp: no dyspnea, lungs clear

CV: CRT 2s, no murmur

Abdo: soft, no HSM, not distended or tender

Skin: tender abscess behind the right ear and right cheek with bad-smelling pus discharge

Admission Lab Results

CBC: Hb 104 g/L ; Ht 33% ; Plat 408 ; WBC 13.2 (Neutrophils 8.1, Lymphocytes 4.3)

ESR 48 ; PPD neg. ; malaria neg.

Initial Management I&D of abscess in OT signs of mastoiditis seen

Pus from abscess and mastoid bone sent for culture IV Cloxacillin and IV Ceftriaxone Paracetamol and morphine for pain Wound inspection & dressing daily under sedation

Initial Hospital CoursePatient continued spiking fevers, wound not improved, abdomen became distended, developed dyspnea, signs of shock

Microbiology results few days after admission Pus culture: Burkholderia pseudomallei

Sensitive: cipro, amox-clav, ceftriaxone Resistant: ampicillin, gentamicin, trimethoprim

Next Investigations & Management Transfer to ICU for sepsis/peritonitis Cloxa stopped, IV Augmentin and IV Metronidazole added CXR: bilateral infiltrates Abd U/S: large amount purulent abdominal ascites; multiple lesions (micro-abscesses) on liver and spleen Sent to OT for peritonitis

Remaining Course

Patient slowly improved after abdominal surgery and change in antibiotic regimen

Final Diagnoses

1. Mastoiditis and post-auricular abscess from melioidosis

2. Sepsis, pneumonia, and peritonitis from melioidosis

3. Multiple visceral abscesses from melioidosis Discharged after total of one month hospitalization with

PO Augmentin and Doxycycline for 2 months

History of Present Illness12 year old boy presented with 3 months of illness. It started with pain and swelling on the right cheek and behind the right ear and then developed day by day to pus discharge associated with low grade fever. His appetite was okay and he was not malnourished

Past Medical History Chronic ear discharge for nearly 2 years Antibiotic at home and dressing change at health center Never hospitalized, no immunizations No TB contact No evidence of immune deficiency

Abstract

Melioidosis is a relatively uncommon infectious disease caused by the gram negative bacterium, Burkholderia pseudomallei. The majority of reported cases of melioidosis are from Thailand and northern Australia. Here is a case report from Cambodia of a pediatric patient who presented with fever, chronic ear discharge, mastoiditis, and a post-auricular abscess with fistula. He later developed shock and peritonitis and was also later found to have visceral abscesses. His pus culture grew Burkholderia pseudomallei. He recovered once the diagnosis of melioidosis was established and appropriate treatment was started.

Poster ID: CLP005 Poster ID: CLP005

Admission CXR CXR 2 wk later