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Early identification of infectious disease depends on high index of suspicion, local epidemiology data and heuristic experience of the attending physician.
33-year old gentleman with Type I Diabetes was seen for left flank pain and fever for 3 days. There was no diarrhoea, vomiting or dysuria. No significant travelling history elicited. He was tachycardic and feverish but was neither hypotensive nor tachypnoeic. Apart from positive renal punch other examinations were normal. The patient is hyperglycaemic with a slightly elevated lactate. Other investigations were normal. Initial managing team treated him as renal colic with uncontrolled Diabetes in observation ward. Reassessment 2 hours later showed a persistent flank pain with minimal skin erythema. Further probing questioning revealed discovered a suspicious travel history of multiple exposures to soil from his work as a palm oil estate supervisor. A working diagnosis of severe sepsis due to splenic abscess secondary to melioidosis was made. IV Unasyn and adequate fluid resuscitation was given. Formal Ultrasound showed Serratus Anterior abscess. Burkholderia pseudomallei was isolated. Patient was discharged weeks later after appropriate antibiotic course.
Discussion and Conclusion
Melioidosis is an infectious disease caused by a gram-negative bacterium, Burkholderia pseudomallei, found in soil and water. It is of public health importance in endemic areas, particularly in Southern Thailand, Malaysia and Northern Australia. Patient with diabetes is particularly susceptible with grave outcome. Since the organism is able to withstand a harsh environment, it is very resistant to antibiotic and can lie dormant in the body for years. Therefore antibiotic choice should be organism specific with a prolong course up to 6 month. A 10-years sample from IMR discovered Augmentin, Bactrim, Cefotaxim and Imipenem has the highest sensitivity compared to Ciprofloxacin and Tazosin. From this study it is suggested to give a combination of antibiotic is necessary for total eradication.
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