Melioidosis as a cause of femoral osteomyelitis and multifocal intramuscular abscess around the hip joint in a farmer: a case report

Abstract

Melioidosis is a potentially fatal infectious disease caused by the soil transmitted saprophyte Burkholderia pseudomallei. Though Sri Lanka being considered a non endemic country, with the increasing number of cases reported recently there is mounting evidence that the disease is emerging here. Osteomyelitis caused by Burkholderia psuedomallei infection is uncommon and only few cases were found in the literature. We report a case of proximal femoral osteomyelitis and multifocal intramuscular abscess around the hip joint caused by Burkholderia psuedomallei in a Sri Lankan farmer. A 57 year old Sinhalese male farmer was admitted with intermittent high grade fever and left hip pain for 3 weeks. He was found to have diabetes. Ultrasound scan of the left hip joint revealed a joint effusion of 1 cm. Whole body anterior and posterior delayed images of a Tc-99m MDP bone scan demonstrated intense tracer uptake in the left proximal femur and the CT pelvis revealed a left side multi focal intramuscular abscess around the hip joint and proximal femur osteomyelitis. The CT guided aspiration of the intramuscular abscess fluid yielded a growth of gram negative bacilli, identified as pseudomonas species. Blood for antibodies for Burkholderia psuedomallei revealed a positive result at a titre of 1:320. He was diagnosed as having probable melioidosis with multifocal intramuscular abscess around the left hip joint and left proximal femoral osteomyelitis. He responded to intravenous meropenem 1 g twice a day and was continued for 4 weeks and was discharged on maintenance regime of oral cotrimoxazole 1920 mg twice a day and oral doxycycline 100 mg twice a day for 20 weeks. Our patient remained asymptomatic after 6 months of follow up and a subsequent ultrasound and CT images showed full resolution of the osteomyelitis and failed to demonstrate any abscess formation. This case alerts clinicians regarding the unusual aetiology of osteomyelitis caused by Burkholderia psuedomallei especially in patients with diabetes and those who have prolonged contact with soil. In such situations early institution of appropriate antibiotics will be life saving and a prolonged maintenance therapy with oral antibiotics is essential to prevent recrudescence of the infection.

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