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Infection

Case Report

A Case of Imported Melioidosis Presenting as Prostatitis A.M. Heyse, J. Dierick, H. Vanhouteghem, F. Ameye, D. Baert, P. Burvenich, G. Wauters

Abstract We report a case of melioidosis in a previously healthy Belgian man. He presented with septicemia and prostatic abscesses 1 week after a trip to Vietnam. Burkholderia pseudomallei was isolated from multiple hemocultures. He was treated successfully with intravenous ceftazidime and trimethoprim-sulfamethoxazole, followed by a per-oral maintenance therapy of amoxicillin-clavulanate with supplementary amoxicillin. There was no need for surgical drainage. This is the second reported case of melioidosis in Belgium. Infection 2003; 31: 60–62 DOI 10.1007/s15010-002-2112-3

Introduction Melioidosis, a tropical disease caused by Burkholderia pseudomallei, is common in southeast Asia and northern Australia [1–4]. An increasing number of cases is reported among tourists returning from endemic areas. There was one previously reported case in Belgium [5]. We report a case of imported melioidosis presenting septicemia and prostatic abscesses.

Case Report A 38-year-old man was admitted to the hospital because of fever. The fever started 1 week after he returned from a 3-week trip to Vietnam. He complained of a painful miction and he had difficulties in voiding.Apart from mosquito bites, he had no other arthropod bites. He had two healed wounds, one on the ankle, one on the knee. The latter wound was caused by a fall on a day trip in the north of Vietnam while walking barefoot. The patient was previously healthy. Temperature was 39 °C, pulse was 120 and respiration rate was 20. Blood pressure was 125/70 mm Hg. Physical examination revealed no abnormalities. There were 124 leukocytes and 12 erythrocytes per field in the urine. Direct examination showed gram-negative rods. Laboratory findings included a leukocyte count of 24.1 109/l (with 82% polymorphonuclear cells, 8% monocytes and 10% lymphocytes) and a C-reactive protein (CRP) level of 28.8 mg/dl (normal < 0.5 mg/dl). The other blood results were normal. No pulmonary infiltrates were visible on the radiograph of the chest. An ultrasonographic examination of the abdomen

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showed a cortical cyst of 2.6 cm in the left kidney.A transrectal ultrasound scan of the prostate revealed a prostatitis with two abscesses, one in the left and one in the right prostate lobe. There were several smaller zones of abcedation.These findings were confirmed by computed tomography (CT) (Figure 1). The patient was treated empirically with intravenous ciprofloxacin, initially 200 mg twice a day, but we increased the dose to 400 mg twice a day because the fever persisted. He had an indwelling urinary catheter for 2 days because of urinary retention caused by the swollen prostate. Serologic tests, microscopical examination of a blood smear and a stool specimen were negative. The urine culture and three blood cultures revealed gramnegative rods identified as B. pseudomallei. The isolate was sensitive to ceftazidime, trimethoprim-sulfamethoxazole (TMP-SMZ), imipenem and amoxicillin-clavulanate. It was intermediately sensitive to ciprofloxacin and doxycyclin and resistant to ampicillin, most of the cefalosporins and aminoglycosides. The therapy was switched to intravenous ceftazidime (120 mg/kg/d) and TMP-SMZ (60 mg/kg/d). A CT scan of the abdomen and the thorax and a scintigraphic study with gallium revealed no other foci of infection. We gave intravenous ceftazidime and TMP-SMZ for 2 weeks. The patient rapidly became afebrile. The CRP and the leukocyte count normalized during this period.This excellent clinical and biochemical response enabled us to switch to oral maintenance therapy for 6 months: amoxicillin-clavulanate 500 mg 4/d, given with supplementary amoxicillin 500 mg 4/d (amoxicillin 60 mg/kg/d). Ultrasonographic follow-up showed gradually decreasing abscesses that disappeared after 6 months of per-oral antibiotic therapy. No surgical intervention took place.

A.M. Heyse (corresponding author), D. Baert, P. Burvenich Dept. of Internal Medicine, AZ Maria Middelares St-Jozef, Kortrijkse steenweg 1026, B-9000 Ghent, Belgium; Phone: (+32/92) 23-4933, Fax: -00543, e-mail: [email protected] J. Dierick, H. Vanhouteghem Dept. of Clinical Biology, AZ Maria Middelares St-Jozef, Ghent, Belgium F. Ameye Dept. of Urology, AZ Maria Middelares St-Jozef, Ghent, Belgium. G. Wauters Dept. of Microbiology, UCL (Université Catholique de Louvain), Ave. Hippoccrate 54, B-1200 Brussels, Belgium.

Received: July 30, 2001 • Revision accepted: April 23, 2002

Infection 31 · 2003 · No. 1 © URBAN & VOGEL

A.M. Heyse et al. Melioidosis Presenting as Prostatitis

Figure 1. Computed tomography showing an enlarged prostate with two abscesses measuring 3.05 cm and 2.32 cm, respectively.

Discussion Melioidosis is endemic in southeast Asia with the greatest concentration of cases reported in Thailand, Singapore, Malaysia and northern Australia [1–4, 6]. Melioidosis is gradually being recognized as an emerging infectious disease in Vietnam [7]. The disease has been reported in Myanmar, Laos, Cambodia, the Indian subcontinent, Bangladesh and China [6]. Presumably it is widespread in tropical southeast Asia [6]. B. pseudomallei, the causal pathogen of melioidosis, is a natural saprophyte that can be isolated from soil and water. Humans most frequently contract melioidosis by soil contamination of skin abrasions. Our patient probably became infected during a trip in the north of Vietnam walking barefoot through rice paddies, where he was injured. The importance of risk factors for melioidosis has been documented: diabetes, chronic lung disease, chronic renal disease, occupational exposure, excessive alcohol consumption and possibly the consumption of kava (an extract of the root of a plant used as an alternative to alcohol by Aboriginal communities) [4, 8]. Our patient did not have any risk factors. B. pseudomallei grows readily on most routine culture media. Culture remains the cornerstone of the diagnosis. Virtually every organ can be infected. Pulmonary infection is the most common form of the disease. In many patients secondary abscesses dominate the clinical picture. Our patient presented bacteremia and prostatic abscesses. Prostatic melioidosis has been well described [9–15] but was considered to be rare. However, in a recent prospective study of 252 cases in northern Australia [4], the presence of prostatic abscesses in 18% of men is far higher than reported in the studies from Thailand [10].


Untreated acute melioidosis is rapidly fatal with a mortality rate of 95% before the use of antibiotics.With the use of ceftazidime regimens, mortality has been reduced to 30–37% [16]. Maintenance therapy is required to prevent relapses, which occur in up to 23% of patients [17]. Treatment usually consists of an intensive phase of at least 14 days of intravenous antibiotics, primarily ceftazidime but more recently also meropenem or imipenem for critically ill patients [16, 18, 19]. Some centers associate TMP-SMZ with the intensive phase [20]. This phase is followed by an eradication phase of oral antibiotics for at least 3 months, consisting of the conventional four-drug regimen (chloramphenicol, doxycyclin, TMP-SMZ) or more recently mono- or bitherapy with doxycyclin or TMP-SMZ [4]. Amoxicillin-clavulanate can be used, often given with supplemental amoxicillin [21]. There is controversy about the role of surgery in treating melioidosis [17]. Prostatic abscesses usually require drainage [4], transurethral resection of the prostate or transrectal ultrasound-guided drainage [15]. However, successful antibiotic treatment of prostatic abscesses has been described [14]. We treated our patient successfully with intravenous ceftazidime and TMP-SMZ for 2 weeks and a per-oral maintenance therapy of amoxicillin-clavulanate combined with supplementary amoxicillin for 6 months. Our case is of interest for three reasons. First of all, the presentation form, a septicemia with prostatic abscesses, is uncommon outside Australia. Secondly, successful treatment of prostatic abscesses with antibiotics without need for surgical drainage proved possible. Thirdly, this is only the second reported case of melioidosis in Belgium. Clinicians should take into account that melioidosis has protean manifestations and melioidosis should be included in the differential diagnosis of a febrile patient who has been to an endemic area.

Acknowledgments We thank Prof. M. Kunnen and M.L. Duyts for printing the photographs.

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