Melioidosis in a Renal Transplant Recipient

Melioidosis, a clinically diverse disease caused by the facultative intracellular gram-negative bacterium, Burkholderia pseudomallei, has been reported from the Indian subcontinent in small numbers. It is likely that this disease is under-diagnosed and under-reported because of lack of clinical suspicion and microbiologic identification (1). We report from India the first case of melioidosis in world literature in a renal transplant recipient. A 45-year-old man, diabetic for many years, presented two and one half years after a cadaver renal transplantation with high fever for 2 weeks and pain over the right ankle joint for 5 days, suggestive of a septic arthritis. He had a history of redness of the forefoot 2 weeks before the fever, which resolved without treatment. There were no pulmonary or urinary symptoms or evidence of tuberculosis. Immunosuppression consisted of prednisolone (10 mg/day), azathioprine (1.5 mg/kg/day), and cyclosporine (C0 level: 225 ng/mL; C2 level: 1,050 ng/mL). There were no episodes of rejection. At presentation, patient was leukopenic (White blood cells [WBC]: 2600 cells/μL) with neutrophilia; the serum creatinine was 1.1 mg/dL and had increased blood glucose levels but without ketoacidosis. The chest radiograph and ultrasonography of the abdomen and pelvis were normal. Initially, the blood culture and subsequently ankle joint aspirate grew B. pseudomallei, which was confirmed biochemically and serologically (2). Urine was sterile. Patient was treated with injected ceftazidime 1 g twice per day for 3 weeks and with co-trimoxazole 480/80 mg twice per day orally for 3 months. Tablet azathioprine was withdrawn on account of leucopenia and reintroduced at a lower dose during the third week. There was defervescence on the fifth day of therapy, and the patient could bear weight on the right lower limb after 3 weeks of therapy. There was no renal dysfunction. This patient, at risk with diabetes mellitus and immunosuppression, presented with a septicemic form of melioidosis associated with septic arthritis, possibly secondary to seeding by a hematogenous infection. Chronic renal failure, urolithiasis, chronic lung disease, and thalassemia also increase the risk for symptomatic melioidosis. The most important risk factors for melioidosis are diabetes, excessive alcohol ingestion, and chronic renal disease, although this is the first report of melioidosis in a renal transplant recipient. It is possible that in some patients with a latent focus, the recrudescence is prevented with co-trimoxazole prophylaxis for Pneumocystis carinii, often used after transplantation for 6 months. Subsequently, recrudescence or acute infection may occur. Relapses occur in 10% to 13% of cases associated with poor adherence to eradication therapy for 3 months. In chronic melioidosis, radiology of the chest may reveal infiltrates that are cavitating, nodular, or streaky with fibrotic changes mimicking tuberculosis. It is possible that some cases of fever of uncertain origin after transplantation wherein melioidosis was missed would get treated empirically with ceftazidime with good initial response, although the microbiologic cure would require prolonged therapy. An indirect immunoglobulin (Ig)G enzyme-linked immunosorbent assay (ELISA) developed in our center to detect antibodies to B. pseudomallei in serum samples (cutoff optical density of 0.36) has a sensitivity of 83.3% and a specificity of 92.9% (3). Such tests serve to screen for the disease, whereas cultures confirm the diagnosis. This first report of melioidosis in a diabetic renal transplant recipient should alert physicians in endemic regions and in areas where melioidosis is an emerging infection to include such a diagnostic and therapeutic possibility in the evaluation of immunosuppressed hosts presenting with febrile syndromes. Immunosuppressed hosts in regions with no melioidosis presenting with fever of unknown origin after travel to endemic regions may be infected with B. pseudomallei. George T. John Ishthiaq Ahmed Chakko K. Jacob Mary V. Jesudason M. K. Lalitha 1Department of Nephrology Christian Medical College Vellore Tamil Nadu India 2Department of Microbiology Christian Medical College Vellore Tamil Nadu India