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Paper text:
it is capable of causing various clinical manifestations like pneumoniae , septicaemia , arthritis , abscess etc . and is associated with high morbidity and mortality .
cases have been reported from southeast asian countries like thailand , malaysia and vietnam etc . in india ,
most cases have so far been reported from the southern states like kerela and tamil nadu .
alhough not so uncommon in india but early and correct diagnosis and institution of proper antimicrobial therapy is important in order to reduce morbidity and mortality and have a favourable outcome .
here we report a case of melioidosis which probably was undiagnosed for long but was saved due to correct and timely intervention .
he presented with swelling of ankles and pain , redness on right ankle for 7 days and fever , cough , breathlessness from last 1 month .
two months back he was treated for fever with ceftriaxone as his widal test was reactive . at about the same time
, he was incidentally diagnosed with diabetes mellitus ( dm ) . on treatment , though his symptoms subsided to some extent , during last 7 days he again complained of high fever , worsening breathlessness and loss of appetite .
his body temperature was 102 f , blood pressure 90/70 mm hg , respiratory rate 50/min , and heart rate 128/min .
laboratory investigations revealed that multiple hematological and biochemical parameters were deranged [ table 1 ] .
his chest x - ray showed homogenous consolidation in upper left lobe and diffuse alveolar opacities in remaining part of lung [ figure 1 ] .
chest x - ray showing left upper lobe consolidation post admission his condition further deteriorated and had clinical evidences of acute respiratory distress syndrome , deranged blood gases , and was in respiratory distress .
his oxygen saturation was 78% . with this background , he was put on ventilator and started with piperacillin / tazobactum and clindamycin . on day 2
non fermenting pale colonies with metallic sheen were isolated next day on blood agar and mac conkey agar [ figure 3 ] ; the isolate was further processed on microscan walkaway 96 si .
gram negative bacilli with safety pin appearance on gram stain colonies of bukhlorderia pseudomallei on mac conkey agar on day 4 , the isolate was identified as burkhlorderia pseudomallei , sensitive to imipenem , cotrimoxazole / sulfamethoxazole , tetracycline and resistant to ceftazidime .
later on , both his blood cultures and pus drained from right leg [ figure 4 ] also grew b. pseudomallei .
based on the sensitivity report , antibiotic was changed to a combination of imipenem and doxycycline .
patient showed improvement , his fever subsided , total counts decreased , oxygen saturation was 100% , and was extubated on day 8 .
pus drained from right ankle his antibiotics were continued and after complete recovery and improvement of his liver and renal parameters he was discharged on day 20 .
b. pseudomallei is an environmental inhabitant and is widely disseminated in soil , water , paddy fields , etc .
it is geographically restricted to tropical and subtropical areas of australia and southeast asian countries . in india , quite a number of cases were reported though many are still underreported due to its protean manifestations .
most of these were reported from the southern part though melioidosis may be more widely prevalent .
two of the cases reported from tamil nadu actually originated from eastern part of india .
our patient was exposed to recent floods , which could be the source of infection .
review of cases in india active infection have been predisposed to occur in patients with many underlying conditions like dm , renal disease , and hiv postive . in our patient diabetes was an incidental finding during the course of investigation .
review of literature reveals successful treatment with a combination of ceftazidime and co - trimoxazole [ table 2 ] .
our strain was resistant to ceftazidime and therefore patient was put on imipenem and doxycycline .
carbepenems have a better response against b. pseudomallei . the patient was put on maintenance therapy of doxycycline , trimethoprim sulfamethoxazole and is doing well .
this case was probably missed due to lack of clinical awareness and correct microbiological diagnosis .
a high index of suspicion is needed for diagnosis due to its varied clinical presentations . at the same time
we were able to successfully treat the case by institution of correct antimicrobials based on microbiology feedback .
burkhloderia pseudomallei has recently gained importance as an emerging pathogen in india . 
 it causes various clinical manifestations like pneumoniae , septicaemia , arthritis , abscess etc . 
 cases have been reported from southeast asia mainly thailand , malaysia , vietnam , etc . in india , few cases have been reported mainly from the southern part of the country . patient was a 65-year - old male and presented with fever 1 month back , cough and breathlessness for same period , swelling on both ankles from 7 days . 
 b. pseudomallei was isolated from endotracheal secretions , blood cultures , leg wound . 
 he was successfully treated with imipenem and doxycycline and put on maintenance therapy now , and is currently doing well .