pulmonary miloedosis

1. PULMONARY MELOIDOSIS

2. HISTORY AND COMPLAINTS
• 50 YEARS OLD MALE
• NO PRIOR COMORBIDITIES
• CAME WITH COMPLAINTS OF
1. COUGH SINCE 10 DAYS OCCASONAL WHITISH EXPACTORATION
2. INCREASED SWEATING EPISODE 2 DAYS BACK
3. CHEST PAIN DURING COUGHING
4. LOSS OF APPETITE
• H/O SIMILAR COMPLAINTS 1 MONTH BACK, TOOK TREATMENT ON OPD
BASIS.
• COVID IN 2020, MANAGED SYMPTOMATICALLY

3. • NO H/O BLOOD IN SPUTUM/SHORTNESS OF BREATH
• NO H/O SIGNIFICANT LOSS OF WEIGHT
• NO BLADDER/BOWEL COMPLAINTS
• NO H/O TUBERCULOSIS/ASTHMA/PNEUMONIA IN PAST
• NO KNOWN DRUG ALLERGIES.

4. COURSE IN HOSPITAL
• HE HAD TACHYCARDIA, TACHYPNOEA AND HYPOTENSION WHEN CAME TO ER,
WHICH WAS MNAGED WITH IV FLUIDS, NEBULISATION, IV ANTIBIOTICS (INJ
AUGMENTIN) AND OTHER SUPPORTIVE CARE.
• CHEST X RAY DONE SHOWED RIGHT UPPER LOBE CAVITATORY LESION.

5. Investigations
• CRP 230.4 mg/L,D DIMER 1.00 µg/ml,WBC COUNT 10.12 10³/mm.
• HIV, HBSAG AND HCV WAS NEGATIVE.
• SPUTUM GENE X PERT MTB WAS NEGATIVE, AFB STAIN WAS
NEGATIVE.SPUTUM CULTURE REPORTED NO PATHOGEN.
• 2D ECHO DONE ON 1/2/2023 SHOWED FAIR LV SYSTOLIC FUNCTION.
LVEF=50-55 % AT REST. NO RWMA. NO DD. TRIVIAL MR. MILD TR.
MILD PAH

6. • HRCT CHEST WITH CONTRAST DONE ON 1/2/2023 SHOWED CAVITATORY FOCUS IN THE
RIGHT APEX ANTERIORLY WITH SURROUNDING CONSOLIDATION AND GROUNDGLASS
ATTENUATION.MEDIASTINAL LYMPHADENOPATHY.FEW PARA-AORTIC NODES AND
COUPLE OF HYPODENSE FOCI IN THE SPLEEN.THESE FINDINGS SUGGEST INFECTIVE
AETIOLOGY INCLUDING THE POSSIBILITY OF KOCH'S. HISTOPATHOLOGICAL AND CULTURE
CORRELATION ARE SUGGESTED.BILATERAL RENAL CALCULI, ONE ON THE LEFT
MEASURING 8 MM AND FEW TINY ON THE RIGHT MEASURING 2-3 MM.

7. BRONCHOSCOPY DONE
• GENE XPERT NEGATIVE
• HE HAD INTERMITTENT FEVER SPIKES, ANTIBIOTICS WERE UPGRADED
TO INJ PIPTAZ AND TAB LEVOFLOXACIN.
• IN VIEW OF PERSISTANT PIPTAZ STOPPED, INJ MEROPENEM, INJ
AMIKACIN STARTED.
• HIS BAL CULTURES SHOWED GROWTH OF BURKHOLDERIA
PSEUDOMALLEAI
• HE WAS STARTED ON INJ CEFTAZIDIME AND TAB SEPTRAN DS. OTHER
ANTIBIOTICS WERE STOPPED.

8. COURSE CONTINUED
• CRP SHOWED DOWNWARD TREND. FEVER SPIKES SUBSIDED
• HE WILL REQUIRE 3-4 WEEKS OF INJ CEFTADIZIME, AND TAB SEPTRAN
DS AS MAINTAINENCE THERAPY FOR 3 MONTHS
• HE COMPLETED 1 WEEK OF INJ CEFTAZIDIME AND HE WAS
DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH
ADVISE TO CONTINUE INJ CEFTAZIDIME AT HOMETOWN

9. SOME SPECIAL TESTS
• Gram stain: Short Bipolar Stained Gram-Negative Bacteria, showing
'Safety-pin Appearance’.
• Biochemical tests :
1. Cytochrome oxidase test – POSITIVE
2. Tube Catalase test - Positive
3. Amino Acid Utilization Test: Arginine Dihydrolysed
4. Citrate utilization test - Citrate utilized

10. • Identification of B. pseudomallei using ‘three-disk diffusion test’
1. Colistin 10 Resistant
2. Gentamicin 10 Resistant
3. Amoxicillin- Clavulanic acid 20/10 Sensitive
• Monoclonal antibody based Latex Agglutination for B. pseudomallei:
Positive
• Polymerase Chain Reaction (PCR) assay targeting T3SS1 gene: Positive
• AST
1. Ceftazidime 10 Intermediate*
2. Doxycycline 30 Sensitive
3. Meropenem 10 Sensitive
4. Trimethoprim-Sulfamethoxazole 1.25/23.75 Intermediate*

11. 12TH Feb 2023
8TH FEB 2023