Emma Birnie1, Jelmer Savelkoel2, Frans Reubsaet3, Joris J T H Roelofs4, Robin Soetekouw5, Saskia Kolkman6, Anne Lia Cremers7, Martin P Grobusch7, Daan W Notermans3, W Joost Wiersinga8. 1. Center for Experimental and Molecular Medicine and Melioidosis Expertise Center, Amsterdam UMC, Location Academic Medical Center (AMC), Amsterdam Infection & Immunity Institute, University of Amsterdam, Amsterdam, the Netherlands. Electronic address: e.birnie@amc.uva.nl. 2. Center for Experimental and Molecular Medicine and Melioidosis Expertise Center, Amsterdam UMC, Location Academic Medical Center (AMC), Amsterdam Infection & Immunity Institute, University of Amsterdam, Amsterdam, the Netherlands. 3. Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands. 4. Department of Pathology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands. 5. Spaarne Gasthuis, Haarlem, the Netherlands. 6. Department of Radiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands. 7. Center of Tropical Medicine and Travel Medicine, Division of Infectious Diseases, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands. 8. Center for Experimental and Molecular Medicine and Melioidosis Expertise Center, Amsterdam UMC, Location Academic Medical Center (AMC), Amsterdam Infection & Immunity Institute, University of Amsterdam, Amsterdam, the Netherlands; Division of Infectious Diseases, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands. Electronic address: w.j.wiersinga@amc.uva.nl.
Abstract
BACKGROUND: Melioidosis, caused by the Gram-negative bacterium Burkholderia pseudomallei, is an opportunistic infection across the tropics. Here, we provide a systematic overview of imported human cases in a non-endemic country over a 25-year period. METHODS: All 55 Dutch microbiology laboratories were contacted in order to identify all B. pseudomallei positive cultures from 1990 to 2018. A response rate of 100% was achieved. Additionally, a systematic literature search was performed, medical-charts reviewed, and tissue/autopsy specimens were re-assessed. RESULTS: Thirty-three travelers with melioidosis were identified: 70% male with a median-age of 54 years. Risk factors were present in most patients (n = 23, 70%), most notably diabetes (n = 8, 24%) and cystic fibrosis (n = 3, 9%). Countries of acquisition included Thailand, Brazil, Indonesia, Panama, and The Gambia. Disease manifestations included pneumonia, intra-abdominal abscesses, otitis externa, genitourinary, skin-, CNS-, and thyroid gland infections. Twelve (36%) patients developed sepsis and/or septic shock. Repeat episodes of active infection were observed in five (15%) and mortality in four (12%) patients. Post-mortem analysis showed extensive metastatic (micro)abscesses amongst other sites in the adrenal gland and bone marrow. CONCLUSIONS: The number of imported melioidosis is likely to increase, given rising numbers of (immunocompromised) travelers, and increased vigilance of the condition. This first systematic retrospective surveillance study in a non-endemic melioidosis country shows that imported cases can serve as sentinels to provide information about disease activity in areas visited and inform pre-travel advice and post-travel clinical management.
BACKGROUND:Melioidosis, caused by the Gram-negative bacterium Burkholderia pseudomallei, is an opportunistic infection across the tropics. Here, we provide a systematic overview of imported human cases in a non-endemic country over a 25-year period. METHODS: All 55 Dutch microbiology laboratories were contacted in order to identify all B. pseudomallei positive cultures from 1990 to 2018. A response rate of 100% was achieved. Additionally, a systematic literature search was performed, medical-charts reviewed, and tissue/autopsy specimens were re-assessed. RESULTS: Thirty-three travelers with melioidosis were identified: 70% male with a median-age of 54 years. Risk factors were present in most patients (n = 23, 70%), most notably diabetes (n = 8, 24%) and cystic fibrosis (n = 3, 9%). Countries of acquisition included Thailand, Brazil, Indonesia, Panama, and The Gambia. Disease manifestations included pneumonia, intra-abdominal abscesses, otitis externa, genitourinary, skin-, CNS-, and thyroid gland infections. Twelve (36%) patients developed sepsis and/or septic shock. Repeat episodes of active infection were observed in five (15%) and mortality in four (12%) patients. Post-mortem analysis showed extensive metastatic (micro)abscesses amongst other sites in the adrenal gland and bone marrow. CONCLUSIONS: The number of imported melioidosis is likely to increase, given rising numbers of (immunocompromised) travelers, and increased vigilance of the condition. This first systematic retrospective surveillance study in a non-endemic melioidosis country shows that imported cases can serve as sentinels to provide information about disease activity in areas visited and inform pre-travel advice and post-travel clinical management.