Melioidosis presenting as septic arthritis in Bengali men in East London

Sir, Melioidosis can be a fatal disease [1] and is endemic in northeastern Thailand [2] and northern Australia. Melioidosis is not endemic in the Indian subcontinent, but it has been described in travellers from Bangladesh [3, 4]. It is caused by the bacterium Burkholderia pseudomallei, which is found in moist soil and water in the tropics [5], and can enter the human host by inoculation, and perhaps by ingestion and inhalation [6]. The incubation period is from a few days to many years, and immunosuppression, diabetes mellitus and thalassaemia can occur concurrently [7]. The disease has protean manifestations ranging from localized abscess formation to disseminated abscesses, septicaemia and shock [8–11]. Subacute melioidosis presents with fever, weight loss and suppurative abscesses involving numerous anatomical sites. Musculoskeletal melioidosis cannot be clinically differentiated from other infective causes or rheumatoid disorders [7]. In May 1998, a 47-yr-old Bengali man presented with a painful right elbow and a 3-month history of cough, sweats and weight loss. He had been resident in the UK since 1978 and had a past history of successfully treated pulmonary tuberculosis. He had returned 2 weeks previously from a 5-month holiday in Sylhet, in rural Bangladesh. On examination, he had a fever of 38.5°C and a hot swollen elbow (Fig. 1). Investigation revealed newly diagnosed diabetes mellitus (random glucose 22 mmol/l), a normal peripheral white blood cell count (8×109 /l) and a grossly elevated C-reactive protein (>180 mg/l). The elbow X-ray was normal and the chest X-ray showed cavitation at the right apex. A differential diagnosis of pulmonary tuberculosis with possible joint involvement, septic arthritis and typhoid was made. However, blood cultures taken on two separate occasions and elbow aspirate grew a Gram-negative rod of a `Pseudomonas type'. Further imaging revealed multiple splenic low attenuating lesions and cavitating pulmonary lesions which were thought to be abscesses (Fig. 2). A presumptive diagnosis of melioidosis was made on clinical and microbiological grounds.