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ABSTRACT |
 TOP ABSTRACT INTRODUCTIONCASE REPORTSRESULTS AND DISCUSSIONREFERENCES |
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTSRESULTS AND DISCUSSIONREFERENCES |
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CASE REPORTS |
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TOPABSTRACTINTRODUCTIONCASE REPORTSRESULTS AND DISCUSSIONREFERENCES |
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The 43-year-old patient presented to Royal Darwin Hospital after 4–5 days of fever and a six-week-old non-healing lesion on the right hand. The patient also had type 2 diabetes mellitus. Clinical examination identified large right epitrochlear and axillary lymphadenopathy. Swabs from the hand lesion and purulent fluid drained from axillary lymphadenitis both grew B. pseudomallei. Blood cultures were negative and a computed tomography (CT) abdominal scan identified several small hypodensities in the spleen suggesting splenic abscesses. Melioidosis serology using an indirect hemagglutination assay (IHA) showed a titer of 1:640. He was treated with open drainage of the axillary lymphadenitis, intravenous ceftazidime, and oral trimethoprim/sulfamethoxazole. After four days, the patient was afebrile and the right hand lesion had healed. The lymphadenitis resolved after two weeks of intravenous ceftazidime and he subsequently completed an additional three months of oral trimethoprim/sulfamethoxazole. A repeat CT scan showed that the splenic lesions had completely resolved.
The 50-year-old patient was sent to Royal Darwin Hospital following the diagnosis of melioidosis in his co-worker. He had a similar six-week-old non-healing skin lesion on his right forearm (Figure 1
). Following the onset of the lesion, which was initially purulent, the patient had lethargy and fever but after two weeks the symptoms spontaneously resolved. His only medical risk factor for melioidosis was an estimated average daily alcohol consumption of 60 grams. At admission, the patient was afebrile, with the only abnormalities being the 1-cm diameter forearm abscess and enlarged right epitrochlear lymph nodes with overlying erythema. The skin lesion cultured B. pseudomallei, blood cultures were negative, and IHA titer was 1:5,120. He was treated with two weeks of intravenous ceftazidime together with oral trimethoprim/sulfamethoxazole, followed by three additional months of trimethoprim/sulfamethoxazole. The skin lesion and lymphadenopathy resolved in the first week of therapy.
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Bacterial typing was performed using standard pulsed-field gel electrophoresis (PFGE) protocols,16,17 with the following modifications that we have found to give optimum reproducibility and discrimination. The bacterial cultures were grown overnight (16 hours) in Todd-Hewitt broth (Oxoid Australia) and harvested. Bacterial pellets were resuspended to an optical density at 600 nm of 0.5 in resuspension buffer (10 mM Tris-Cl, pH 8.0, 20 mM NaCl, 100 mM EDTA). The bacterial suspension was then mixed (1:1) with molten 2% low melting point agarose (75% NuiSieve GTG and 25% Seakem Gold agarose; BioWhittaker Molecular Applications, Rockland, ME) and pipetted into PFGE plug molds (Bio-Rad Laboratories, Hercules, CA). The plugs were lysed overnight at 50°C in lysis buffer (1 mg/ml of proteinase K [Roche Molecular Biochemicals, Indianapolis, IN], 10 mM Tris-Cl, pH 8.0, 100 mM EDTA, 0.5% Brij-58, 0.2% sodium deoxycholate, 0.5% sodium lauryl sarcosinate) and then rinsed several times with TE buffer (10 mM Tris-Cl, pH 8.0, 1 mM EDTA) before storage at 4°C. Prior to PFGE, plugs were digested overnight in 1x buffer H with 10 units of Spe I (Roche Molecular Biochemicals). The PFGE was performed using Seakem Gold agarose (1.2%) and CHEF-III DR (Bio-Rad Laboratories) with 14°C recirculated 0.5x TBE buffer (45 mM Tris-borate, 1 mM EDTA) containing 100 µM thiourea.18 The PFGE conditions included a field angle of 120°, a voltage gradient of 6 V/cm, and three-block linear switch times (10–30 seconds for 5.8 hours, 30–40 seconds for 15.6 hours, and 40–90 seconds for 5.4 hours). Concatemerized lambda phage DNA (Promega, Madison, WI) was used as PFGE ladder (50–1,000 kilobases). The PFGE gels were stained with ethidium bromide and digitally photographed using the Gel Doc 1000 gel documentation system (Bio-Rad Laboratories).
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RESULTS AND DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTSRESULTS AND DISCUSSIONREFERENCES |
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), of a type that we have not seen previously in other Northern Territory isolates (Currie B, Mayo M, Gal D, unpublished data), suggesting a common source of infection or perhaps a transfer of infection between mechanics. Subsequent investigations of the garage workshop identified B. pseudomallei in an uncapped container of commercial hand wash detergent (Figure 3A). Several closely related B. pseudomallei strains were isolated and were found to be distinctly different from the clinical strain (Figure 2). It is extremely unusual in endemic locations to find B. pseudomallei in any environmental samples apart from soil and water. Although the clinical strain was not cultured from the detergent, it remains the likely infection source; only a small portion of detergent was cultured and the detergent contained more than one strain of B. pseudomallei.
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) that was used repeatedly by the mechanics to dispense detergent into the palms of their hands. Microbial contamination of antiseptic and disinfectant products is not uncommon and is well documented in the literature.19–23 Melioidosis has been documented in humans following contamination of chlorhexidine/cetrimide (Savlon) antiseptic solution,24 and we have documented a similar outbreak among four cats treated at a single veterinary center.5 The B. pseudomallei-contaminated detergent was replaced with a new container of detergent, which was fitted with a pump dispenser to prevent the possibility of future bacterial contamination. Commercial suppliers subsequently fitted pump dispensers to detergent containers throughout the melioidosis-endemic region of the Northern Territory.
Received January 15, 2004. Accepted for publication April 5, 2004.
Acknowledgments: We are grateful to the Royal Darwin Hospital microbiology staff for providing clinical isolates and assistance with identifying detergent isolates, and the Department of Health and Community Services for providing regional field support.
Financial support: This study was supported by the Australian National Health and Medical Research Council.
Authors’ addresses: Daniel Gal, Mark Mayo, Heidi Smith-Vaughan, Pallave Dasari, Melita McKinnon, Susan P. Jacups, and Bart J. Currie, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811, Australia, Telephone: 61-8-8922-8196, Fax: 61-8-8927-5187, E-mail: bart{at}menzies.edu.au. Andrew I. Urquhart, Department of Health and Community Services, Private Mail Bag 234, Alice Springs, Northern Territory, Australia, Telephone: 61-8-8956-8595, Fax: 61-8-8956-8984. Marilyn Hassell, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory 0811, Australia, Telephone: 61-8-8922-8888, Fax: 61-8-8922-8463.
Reprint requests: Bart J. Currie, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811, Australia.
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This article has been cited by other articles:
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  A. C Cheng, S. P Jacups, D. Gal, M. Mayo, and B. J Currie Extreme weather events and environmental contamination are associated with case-clusters of melioidosis in the Northern Territory of Australia Int. J. Epidemiol., April 1, 2006; 35(2): 323 - 329. [Abstract] [Full Text] [PDF]
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 A. C. Cheng and B. J. Currie Melioidosis: Epidemiology, Pathophysiology, and Management Clin. Microbiol. Rev., April 1, 2005; 18(2): 383 - 416. [Abstract] [Full Text] [PDF]
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 A. C. Cheng, D. Godoy, M. Mayo, D. Gal, B. G. Spratt, and B. J. Currie Isolates of Burkholderia pseudomallei from Northern Australia Are Distinct by Multilocus Sequence Typing, but Strain Types Do Not Correlate with Clinical Presentation J. Clin. Microbiol., December 1, 2004; 42(12): 5477 - 5483. [Abstract] [Full Text] [PDF]
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