Melioidosis in Malaysia: A Review of Case Reports

Background: Melioidosis is a tropical infectious disease associated with significant mortality due to early onset of sepsis. Objective: We sought to review case reports of melioidosis from Malaysia. Methods: We conducted a computerized search of literature resources including PubMed, OVID, Scopus, MEDLINE and the COCHRANE database to identify published case reports from 1975 to 2015. We abstracted information on clinical characteristics, exposure history, comorbid conditions, management and outcome. Results: Overall, 67 cases were reported with 29 (43%) deaths; the median age was 44 years, and a male preponderance (84%) was noted. Forty-one cases (61%) were bacteremic, and fatal septic shock occurred in 13 (19%) within 24–48 hours of admission; nine of the 13 cases were not specifically treated for melioidosis as confirmatory evidence was available only after death. Diabetes mellitus (n = 36, 54%) was the most common risk factor. Twenty-six cases (39%) had a history of exposure to contaminated soil/water or employment in high-risk occupations. Pneumonia (n = 24, 36%) was the most common primary clinical presentation followed by soft tissue abscess (n = 22, 33%). Other types of clinical presentations were less common—genitourinary (n = 5), neurological (n = 5), osteomyelitis/septic arthritis (n = 4) and skin (n = 2); five cases had no evidence of a focus of infection. With regard to internal foci of infection, abscesses of the subcutaneous tissue (n = 14, 21%) was the most common followed by liver (18%); abscesses of the spleen and lung were the third most common (12% each). Seven of 56 males were reported to have prostatic abscesses. Mycotic pseudoaneurysm occurred in five cases. Only one case of parotid abscess was reported in an adult. Of the 67 cases, 13 were children (≤ 18 years of age) with seven deaths; five of the 13 were neonates presenting primarily with bronchopneumonia, four of whom died. Older children had a similar presentation as adults; no case of parotid abscess was reported among children. Conclusions: The clinical patterns of cases reported from Malaysia are consistent for the most part from previous case reports from South and Southeast Asia with regard to common primary presentations of pneumonia and soft tissue abscesses, and diabetes as a major risk factor. Bacteremic melioidosis carried a poor prognosis and septic shock was strong predictor of mortality. Differences included the occurrence of: primary neurological infection was higher in Malaysia compared to reports outside Malaysia; internal foci of infection such as abscesses of the liver, spleen, prostate, and mycotic pseudoaneurysms were higher than previously reported in the region. No parotid abscess was reported among children. Early recognition of the disease is the cornerstone of management. In clinical situations of community-acquired sepsis and/or pneumonia, where laboratory bacteriological confirmation is not possible, empirical treatment with antimicrobials for B. pseudomallei is recommended. Author Summary: Melioidosis is a bacterial infection occurring in tropical regions of the world. It has been regularly reported from Southeast Asia and Northern Australia and in recent years, reported from South Asia, China and Brazil. The disease can affect any organ in the body, and commonly presents as a lung infection and/or multiple abscesses in internal organs; diabetes is the most common predisposing factor. Melioidosis is associated with a high rate of death because of the early spread of infection to the blood. Although the general clinical presentations of the disease are similar across regions, some regional differences are reported. Therefore, we reviewed case reports of melioidosis from Malaysia. The cases reported from Malaysia were similar to cases reported from South and Southeast Asia with regard to main presentations of pneumonia and soft tissue abscesses and diabetes as a major risk factor; spread of infection to the bloodstream resulted in a greater likelihood of death. Differences were a higher occurrence of neurological presentations, and abscesses of prostate gland, liver and spleen and aneurysms of major blood vessels than previously reported. Abscess of the parotid gland in children was not common. Early diagnosis and treatment including initiating treatment in suspicious cases is crucial to prevent death.