Melioïdosis Faculty of Medical Sciences 8 October 2006 Dr Valy KEOLUANGKHOT Clinical Coordinator Mahosot-IFMT

Introduction (1) First reported in a Burmese patient in 1912 by A.Whitmore and C.S.Krishnaswami 1937, First clinical case of cervical Melioidosis reported in Vietnam; > 400 French and US soldiers infected during the Vietnam War . 1949, epidemic in sheep in Australia (Winton) and 1st clinical human case in Townsville North of Queensland. 1955, 1st clinical case reported inThaïlande with estimated 2000-3000 cases /year. In 1975, 1st reported in France in Zoo from corpse of Prejwalski horse imported from Asia

Introduction (2) 1999, 1st clinical case reported in Lao P.D.R (IDW, Mahosot) in a female farmer, 44 years old No particular underlying disease with F°> 1 month, alteration of General St., productive cough associated with acute bilateral supra-clavicular lymphadenitis Photo by Wellcome Trust- Mahosot Hospital-Oxford Tropical Medicine Research Collaboration

Introduction (3) Systemic zoonotic infection caused by Gram-negative. bacillus : Burkholderia pseudomallei Endemic in SE Asia & Northern territories of Australia Transmission : air (aerosol), skin abrasions Reservoir : surface waters, soil, mud, paddy fields. Main risk factors : rice farmers, DM, chronic kidney failure, thalassemia, steroid intake.

Introduction (4) Infection is rural and seasonal : during the monsoon Common community-acquired infection Clinical manifestations vary from chronic or localized infection to acute disseminated infection (severe septicemia or fulminant disease) Difficult to diagnose: The great clinical mimicker High relapse frequency ~ 15% / year ; ~ 40% inpatient mortality No vaccine available

Etiology B pseudomallei : environmental saprophytic bacteria Gram negative bacillus bipolar staining (safety pin) Mobile, aerobic, catalase and oxidase (+)

Epidemiology (1) Worldwide Distribution / tropical latitude 20° North and 20° South / NE Thailand + North of Australia. Problem of public health : 1st cause of community-acquired septicaemia in NE Thailand and Darwin Bacteria saprophyte : soil, surface water. Arabinose(+) : non pathogenic Arabinose(-) pathogenic Reservoir : soil

Source : A.Cheng et B.Currie: Clinical Microbiology Review, April 2005, vol 18 N°2

Epidemiology (2) Transmission : trans-cutaneous (inoculation), inhalation All age / 40-60 years ; sex ratio Male: Female = 3:2 Seasonal disease: monsoon (June-November) Incidence rate 3.6-5.5/100.000/year in hyper-endemic zone Risk Factors : Farmers DM Renal failure Renal calculi Thalassémie/ Haemoglobin E or H Steroid intake, Alcoolism

Risks factors Mean Age 42 yr. peak 40-60 yr. Season Variation : rainy season Risk factors OR (95%CI) Preexisting renal disease 2.6 (1.5-5.6) Thalassemia 11.8 (2.5-54.5) Malignancy 0.4 (0.1-0.9) Diabetes 4.8 (3.0-7.7) Soil & water exposure 1.8 (0.6-5.4) DM + Soil & water exposure 6.3 (3.8-10.4) Exposure to soil and water in paddy fields Suputtamongkol Y. Intern J Epidemio 1994;23:1082-90 Suputtamongkol Y.CID 1999;29:408-13

Epidemiology of B. pseudomallei in soil in Thailand North 4.4% Northeast 20.4% Melioidosis by region Region Infection Rate/ 100,000 in-pateints North 18 Central 13.4 Northeast 137.9 South 14.4 Central 6.1% South 5.9% Vuddhakul V. Am J Med Hyg 1999;60:458-61.

Pathogenesis Acute Infection : Reactivation : Direct inoculation during work Inhalation Drowning Reactivation : Dormant intracellular after exposure Relapse by same ribotype

Natural history of Melioïdosis Inoculation, Inhalation Ingestion Séroconversion asymptomatique Infection locale (aiguë ou chronique) Résolution Latence Dissémination Sepsie fulminante et mort

Clinical features Clinical manifestations polymorphe : « the great mimicker » Clinical manifestation vary from chronic or localized infection to acute disseminated infection (septicemia) All organes can be infected : lung, liver, spleen, joints, soft tissus, bone, parotid.

Type of infection Disseminated Septicemic Melioidosis (DSM) Non disseminated Septicemic Melioidosis (NSM) Localized Melioidosis (LM) Subclinical Melioidosis (SM)

Disseminated Septicemic Melioidosis Acute manifestation : rapid clinical deterioration ( Septic shock)and development of metastatic abscesses Blood culture positive Multiple organ involvement (>2 organs) Lung : blood borne pneumonia Skin : pustules Liver : multiple abscesses Spleen : multiple abscesses Kidneys High mortality rate : 100% without treatment, 40% with treatment

Non-Disseminated Septicemic Melioidosis Blood culture positive Single or no organ involvement Lung Liver Spleen Musculoskeletal Low mortality rate

Localized melioidosis Chronic manifestation Blood culture negative Single organ involvement Lung : Pneumonia, abscess Liver : abscess (single or multiple) Spleen : abscess(single or multiple) Musculo-skeletal : septic arthritis, osteomyelitis, pustules, abscess, lymphangitis… Low mortality and relapse rate

Subclinical Melioidosis Serology positive Melioidosis-infection due to asymptomatic carrier : Seroconversion + / almost in endemic zone.(Ex : 80% children <4 years in North-east of Thaïlande). Long term Risk of clinical disease (up to 30 years) It is called « Vietnam time Bomb » in Vietnam : 3.5% of american soldiers trops based in Vietnam with serology +. (treatment not necessary, but surveillance is important and required).

Lung Abcess due to B. pseudomallei

Pulmonary Melioidosis Cliché 1 Cliché 2: 10 jrs after Bilateral Alveolar and interstitial Infiltration Cavity with fluid of RUL

Lung Abcess due to B. pseudomallei 2eme cliché 1er cliché

Melioidosis : Skin & soft tissue Abscesses

Melioidosis : Skin & soft tissue Abscesses 2 weeks after treatment Before treatment

Melioidosis in Laos Research collaboration : Welcome Trust- Mahosot- Oxford University, UK 97 cases in Vientiane hospitals(1999-2006) (78 cases Mahosot, 16 cases Settha, 2 cases 103 Hosp., 1 case Mittaphab) 47 septicaemic / disseminated melioidosis : death : 5 cases 50 localised melioidosis : parotid : 20 cases (5 adults) Joint/soft tissues : 14 cases lung abscess : 1 case Lymphadenitis : 3 cases Others : 12 cases

Diagnosis Can not be made clinically, only microbiologically** 1. Gram stain – Gram neg., bipolar staining (safety pin) 2. Culture on Ashdown media : gold standard (48-72 h) material : pus, throat swab, blood culture - colony morphology & color - natural resistance to gentamicin & colistine 3. Direct ImmunoFluorescence (DIF) & latex agglutination test are rapid test for early diagnosis : IF has 73 & 99% sens. & spec. 4. Imaging: search for abscess (found in 15% of patients Hemo +) : Chest X Ray, Ultrasound abdominal /prostate. 5. Serology : not valuable in endemic areas. ** for this reason melioidosis is largely undiagnosed in developing countries lacking lab facilities

Morphology : B. pseudomallei in culture Source : « The Lancet. vol 361 Morphology : B.pseudomallei in culture Source : « The Lancet.vol 361.May 17,2003, Melioidosis, Prof NJ White »

Melioidosis : bottles of Hemoculture Characteristic Burkholderia pseudomallei pellicle

Quantity of B. pseudomallei(ARA-) and B Quantity of B.pseudomallei(ARA-) and B.Thailandensis (ARA+) by region (By Mrs V.Wuthiekanun, Wellcome Unit, FTM,Mahidol University, BKK) ARA- Median (range) Colony forming unit/g ARA+ NE Thailand 68% 500 (1-17.000) 32% 30 (1-1.200) C. Thailand 0% - 100% 10 (1-600) Laos 40 (1-1.200) 100(1-5.800) Southern Vietnam 21% 30(1-2000) 79% 400(1-18.000)

Melioidosis should be suspected in patients 1. With community-acquired sepsis or pneumonia or visceral abscesses or parotid abscess 2. Living in / returning from endemic areas 3. Exposed to soil and water : rice farmers 4. With co-morbidities = particular risk factors (n°1 risk factor is diabetes) 5. With sepsis resistant to usual 1st line antibiotics : penicillin, ceftriaxone, aminoglycosides, macrolides...

Treatment Importance of case management : depend on early and accuracy of diagnosis. Thinking of melioïdosis in patient with community acquired septicemia in patients at risk Septicemic form needs to be treated quickly before confirmation of diagnosis . Localised form need to be confirmed before treatment and all abscesses need to be drained if possible. Treatment of severe form = expensive (424$US); High Mortality, in spite of optimal treatment ~ 40%. Treatment of localised form less expensive = 124 $US; Low mortality

Melioidosis : Principle of treatment Treatment complexe , long, expensive, problem of compliance Long Duration : 5 – 6 months ! 2 phases: Intensive then maintenance required association of lots of drugs : 3 . High doses and IV initiale ( min. 10 days ) Expensive (Ceftazidime, Imipenem = env. 100 US$/d Need to be started without delay (early diagnosis) Late response to treatment : moy 9 d  not conclude too early for treatment failure. Relapse : * taux increased : 10% after treatment adequat ; 20% if treatment < 20 weeks. * delay moy. of relapse = 21 weeks inThailand In children : less severe  treatment more simple and shorter (8 weeks) if has localised disease

Treatment : septiceamic Melioidosis (Mahosot Microbiology Review, no 4, Feb 2006) 1. Intensive TTT : 10 – 14 days Ceftaxidime : IV dose 120 mg/kg/day 3 div.dose less 10 d. Adult 50 Kg 2g IVD every 8 hours. Or Co-Amoxyclav (Augmentin) IV dose 160mg/kg/j div 6 Adult 50 Kg, 1,2g IVD every 4 hours 2 Maintenance TTT Per Os (conventionnal TTT): - Doxycycline 4mg/kg/d in 1 single dose : 12-20 weeks. - Cotrimoxazole 10/50mg/kg/j in 2 div 2 doses : 12-20 weeks. Or - Co-Amoxyclav (Augmentin) 30/15mg/kg/j in 3 div. doses duration = 20 weeks. - Amoxycilline 30mg/kg/j in 3 div. doses = 20 weeks

Treatment : localised Melioidosis (Mahosot Microbiology Review, no 4, Feb 2006) TTT Per os (Conventionnal TTT): Doxycycline 4mg/kg/d in 1 single dose : 12-20 w. Cotrimoxazole 10/50mg/kg/d in 2 div 2 doses : 12-20 weeks. ( adult 50 Kg : 2 tablets 960 mg x 2/d) Or Co-Amoxyclav (Augmentin) 30/15mg/kg/d in 3 div. doses . duration = 20 weeks. Amoxycilline 30mg/kg/d in 3 div. doses = 20 weeks

Follow up and prevention Follow up is necessary once a month after hospital discharge . Protection of wounds during working in paddy fields . Wearing boots and gloves during working with soil. No vaccine available.

Conclusion (1) Melioidosis : emerging disease with tendency of dissemination, with reservoir hydro-tellurique. BGN, aerobic, mobile, bipolar staining( safety pin) One of cause responsible of community acquired septicaemia with high mortality in SE Asia and North Australia Resistant to empiric treatment of community acquired septicemia. Primary infection : seasonal in monsoon

Conclusion (2) Transmission : inoculation + + or inhalation Very common in immunocompromised : DM, Farmers, Renal calculi, Renal failure steroid intake, alcoholism « Great clinical mimicker  »: Clinical diagnosis difficult except Parotid abscess unilateral in children . Septicaemia = always Hemoculture and Throatswab

Conclusion (3): Treatment of septicemia expensive ~ 424 $US Treatment of localized F.less expensive ~ 124 $US Prolonged treatment is necessary for all cases (in spite of TTT, F° persist 10 ~ days) High Mortality in spite of optimal treatment 40%. High relapse frequency 15% and late. Immunity acquired not durable. Prevention : wearing boots, gloves during working with soil. No vaccine available .

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£¿ªº® (1) Tuberculose : F° prolongée, toux chronique avec expectoration purulente, dyspnée, dl thoracique et Rales crépitants. Abcès du poumon à germes pyogéniques : F°élevée, toux productive avec expectoration purulente, dyspnée, dl thoracique, Rales crépitants. Ostéite chronique : F°élevée et prolongée, écoulement séreuse de la jambe amputée. Mélioidose pulmonaire : F°élevée, toux productive avec expectoration purulente, dyspnée, dl thoracique, Rales crépitants. Cultivateur habitée dans une zone endémique

£¿ªº® (3) 4. Examens paracliniques à pratiquer : - NFS, Hz, groupage - Examen direct des crachats : BK et douves et culture. - Hémoculture et prélèvement de gorge pour chercher B.pseudomallei. - Rx thorax : - Glycémie, Créatinine, Azotémie, Ionogramme, Bilan hépatique. - Rx de la jambe D (Tibia et péroné).

£¿ªº® (4) : Résultats NFS à l’admission : Hte: 36% ; Hb: 11g/l ; GB: 12.000/mm3, PN : 86%, Lympho: 14 %, Mono: 2,4%; Plaquettes : 230.000/mm3;Hz : négatif . NFS, VS: Hte: 32% ; Hb: 11g/l ;GR: 3.335.000/mm3 ; GB: 17.300/mm3, PN : 88%, Lympho: 8.4 %, Mono: 3.6 %. MCV: 96; Plaquettes : 299.000/mm3 ;Hz : négatif . VS : 127 et 134 mm/h Glycémie : 105 mg/dl ; Créatininémie : 165UM/l; Bilan hépatique : Bil T : 0.75 et Bil D: 0.30 ; SGOT:40 UI/l; SGPT: 50 UI/l; P.alcaline : 540UI/l

£¿ªº® (5) : Résultats Ionogramme : Na :141, K : 3.05; Chlore : 102 Bicarbonate : 21.8 mmol/l Hémoculture : negative ED crachats : BK et Douves (-) Culture des crachats : Proteus sp. (+) Rx thorax : Abcès du poumon droit Prélèvement de la gorge : B.pseudomallei (+)

Examen bactériologique Prélèvement de gorge sur le milieu de SBCT: Aspect de pellicule blanche à la surface positif à Burkholderia pseudomallei

Aspects radiologiques 1er cliché 2eme cliché

Réponses Diagnostic positif : Abcès du poumon à B.pseudomallei . Traitement : Ceftazidime 120 mg/kg/j div.3 pendant 14 js adapté à la Creatininémie. TTT symptomatique Re-équilibre hydro-électrolytique Conseils au patient : - Suivi régulier le traitement après la sortie pour prévenir la rechute et immunité acquise pas durable

Thank you for your attention

References Chaowagul,W et al 1989: Melioidosis : a major cause of Community-acquired septicemia in Northeastern Thailand. J.Infect.Dis.159, 890-898. N J White : Melioidosis .The Lancet 2003 ; Vol 361: May 17, 2003; 1715-22. Wuthiekanun, V, et al 1996 : Biochemical characteristics of clinical and environnmental isolates of B.pseudomallei. J.Med.Microbiol.1996; 45: 408-412. Phetsouvanh R. et al.: Melioidosis and Pandora’s box in the Lao People’s Democratic Republic. Brief reports: Clinical Infectious Disease 2001;32: 653-654. Wuthiekanun, V.et al : Detection of Burkholderia pseudomallei in soil within the Lao PDR . Journal of Clinical Microbiology, Feb.2005, vol.43, n°2 : 923-924 Wirongrong Chierakul et al : Two randomized controlled trials of Ceftazidime alone vs Ceftazidime in combination with TMP-SMX for the treatment of severe Melioidosis. Clinical Infectious Disease 2005;41: 1105-1113.