Septicemic Melioidosis with Ruptured Splenic Abscess in a Patient with Thalassemia Intermedia.

Sir,

Melioidosis, a bacterial illness was first described in the year 1911, as “Hitherto undescribed glanders-like illness” by Captain Alfred Whitmore and his assistant C. S. Krishnaswami.[1] The organism is a primary soil saprophyte and is endemic in areas with tropical monsoon climate with average annual rainfall (>200 cm). It is an emerging infectious disease in India, and multiple cases have been reported from the Western coastal regions, which has favorable environmental conditions for the survival of the organism.[2] Diabetes mellitus, renal diseases, thalassemia, and occupational exposure through direct contact with soil are the known risk factors for septicemic melioidosis.[3] Thalassemia causes a wide range of immune abnormalities such as decreased T-cell proliferation, decreased complement levels (C3 and C4), defective chemotaxis and phagocytosis by macrophages and neutrophils, and defective natural killer cell function predisposing them to serious infections.[4] We report a young postpartum female from Javadi hills (a tribal area in the Eastern Ghats of south India), with bacteremic melioidosis presenting with acute abdomen secondary to a ruptured splenic abscess, and on further evaluation was diagnosed with underlying thalassemia intermedia.

A young postpartum female presented with left-sided abdominal pain and fever for 10 days. History was significant for decreased effort tolerance and fatigability for the past 10 months. Clinical examination revealed pallor with features of systemic inflammatory response syndrome. Abdomen was peritonitic with moderate splenomegaly and free fluid. Investigations revealed microcytic hypochromic anemia with elevated lactate dehydrogenase levels and peripheral reticulocytosis. Peripheral blood counts showed neutrophilic leukocytosis with toxic changes. Contrast-enhanced computed tomography of the abdomen revealed a hypodense lesion with peripheral enhancement involving the lower pole of spleen measuring 4 cm × 2.2 cm with breech in the capsule and adjacent perisplenic collection with omental and peritoneal thickening [Figure 1]. There was moderate splenomegaly with multiple peripheral wedge-shaped nonenhancing hypodense lesions suggestive of splenic infarcts [Figure 2]. The aspirate from the perisplenic collection isolated Burkholderia pseudomallei, which was confirmed biochemically. She was initiated on intravenous (IV) meropenem (2 g IV every 8th hourly) and underwent laparotomy followed by splenectomy and a peritoneal washout. She had an asymptomatic postoperative period. Hemoglobin (Hb) variant analysis done as a part of the evaluation of hemolytic anemia was suggestive of homozygous beta + thalassemia with HbF of 17% and HbA2 of 7%. She completed 6 months of eradication therapy with oral doxycycline and trimethoprim-sulfamethoxazole and is currently under follow-up.

Figure 1

A 4 cm × 2.2 cm abscess in the lower pole of spleen with breech in the capsule and adjacent perisplenic collection

Figure 2

Peripherally situated wedge-shaped splenic infarcts

The Eastern Ghats, a discontinuous mountain range in southern Tamilnadu, is known for its rich biodiversity and is home for a multitude of tribal population, who practice agriculture. The average rainfall per year is about 800–1600 mm, which makes it a favorable environment for saprophytic organisms.[5] Unpublished data indicate high incidence of hemolytic anemia among these tribal population, most commonly beta thalassemia. The presence of these risk factors predisposed our patient to severe sepsis; however, prompt antibiotics with source controlled to a favorable outcome. This case reiterates the association of thalassemia with septicemic melioidosis and epidemiological studies are warranted in this population to study this association further.

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