Short Report Pulmonary melioidosis in febrile neutropenia: the rare and deadly duet C Mukhopadhyay MD PDCC* K Chawla MD* K E Vandana MD* S Krishna MBBS* K Saravu MD † *Department of Microbiology; † Department of Medicine, Kasturba Medical College and Hospital, Manipal 576104, India Correspondence to: Dr Chiranjay Mukhopadhyay, Department of Microbiology, Kasturba Medical College and Hospital, Manipal 576104, India Email: chiranjay@yahoo.co.in TROPICAL DOCTOR 2010; 40: 165–166 DOI: 10.1258/td.2010.090461 SUMMARY We present the first two fulminant cases of pulmonary melioidosis in febrile neutropenic patients with acute and varied presentations seen in our institution and their fatal outcome. A high index of suspicion coupled with microbiological confirmation can facilitate the adminis- tration of the appropriate therapy in cases of melioidosis that differ from other bacterial infections in terms of presentation and the response to antimicrobials. Introduction Melioidosis is an emerging infectious disease in the coastal belt of Karnataka in Southern India. It is associated with various risk factors such as diabetes, chronic renal failure, male gender and soil exposure. 1,2 Febrile neutropenia is a life-threatening complication of cytotoxic chemotherapy where at least a half of patients have documented or occult infection. 3 Signs and symptoms of infection are often subtle in neutropenic patients due to the reduced inflamma- tory response. Infection with Gram-positive bacteria, increas- ingly drug-resistant pathogens and previously uncommon organisms are now on the rise. Early antibiotic therapy is warranted as infections can progress rapidly. So far melioido- sis in febrile neutropenia has only been presented in case reports and there is a scarcity of data worldwide. 4 We present the first two fulminant cases of pulmonary melioido- sis in febrile neutropenic patients from our institution. Case 1 A 46-year-old non-diabetic school teacher on regular treatment for hypothyroidism was admitted with a two-day complaint of high grade fever, breathlessness and altered sensorium. She was known to have had carcinoma ovary, for which total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node clearance were undertaken two months ago and she was still on chemother- apy. The first three cycles were uneventful: the above com- plaints started 15 days post-fourth cycle. There were no other associated complaints. On examination, she was irritable, semiconscious, tachyp- noeic, febrile and had tachycardia, icterus and hypotension. On auscultation, air entry was bilaterally reduced with right upper zone wheeze. Routine blood investigations showed a leucocyte count of 1500 cells/mm 3 without any countable polymorphs, blood urea 64 mg/L, serum creatinine 2.4 mg/L, serum sodium 123 mEq/L and elevated erythro- cyte sedimentation rate. Liver function tests were deranged. Chest radiograph showed bilateral opacities suggestive of adult respiratory distress syndrome. The presumptive diagno- sis of pneumonia with febrile neutropenic sepsis was made. Sputum and blood samples were sent for bacteriological culture. Empirical treatment with intravenous teicoplanin 400 mg/ 12 h and cefepime 2g/ 8 h was started. The patient’s condition rapidly deteriorated and she succumbed to septicae- mic shock within a few hours of admission despite attempted resuscitation. Burkholderia pseudomallei was isolated from blood culture two days after her death. Case 2 A 35-year-old non-diabetic fisherman presented with high grade fever with chills, productive cough, right-sided chest pain and breathlessness of 10 days’ duration. He had under- gone total gastrectomy for carcinoma of the stomach (T 3 N 3 M 0 ) six months ago, received radiotherapy and was on chemotherapy with 5-florouracil and leucoverin. His current symptoms started during the second round of chemotherapy. On physical examination he had oral ulcers and coarse crepitations on the right side of the chest. Chest radiograph revealed right perihilar and lower zone opacity. Sputum as well as bronchoalveolar lavage (BAL) from right middle and lower lobe had growth of B. pseudomallei. However, blood culture was sterile. Therapy was changed from cefipime to piperacillin-tazobactem after the bacteriologi- cal confirmation. Fluconazole was also administered for oral candidiasis. There was a considerable improvement in the leu- cocyte count after therapy with granulocyte-colony stimulating factor. He was afebrile after 5 days and showed marked clini- cal and radiological improvement after 10 days. He was sent home with cotrimoxazole maintenance therapy for melioido- sis and palliative pain control drugs. However, he was read- mitted after two months with worsening jaundice with total and direct bilirubin of 8 and 6.2 mg%, respectively, asparate aminotransferase 7193 IU, alanine transaminase 3488 IU and alkaline phosphatase 109 IU. The patient succumbed on day four due to advanced metastatic carcinoma with biliary tract obstruction. Tropical Doctor July 2010, 40 165