We report a case of melioidosis and pulmonary tuberculosis co-infection in a 40-year-old diabetic male. The patient presented with chronic cough since two months and intermittent low grade fever since a month. Cough was initially dry and later productive, with no hemoptysis. The patient was initially managed as an outpatient in his village with symptomatic treatment for cough and fever, following which he had temporary relief. A diabetic for 13 years, he was on irregular treatment. He was a non-smoker and non-alcoholic. He was an agriculturist by profession, cultivating rice paddy. He had no past history of tuberculosis and bronchial asthma.
On examination, his temperature was 39.4°C. Dyspnoea, clubbing or lymph node enlargement were not present. Fine crepitations were heard on left upper lobe area of lung. Laboratory investigations showed a total leukocyte count, 8,700/mm3 (normal range, 4,000-10,500) with 68% neutrophils, 1% monocytes, 26% lymphocytes and eosinophils 5%, Erythrocyte sedimentation rate 20 mm/1st hr (normal range, 2-14 mm/ 1st hr), random blood sugar 420mg/dl (normal range, 80-160 mg/dl). Hemoglobin level, liver function test, thyroid function test, renal function tests were within normal limits. Chest X-ray showed cavitory lesion in left apical lobe and no consolidation. Ultrasonography of abdomen was normal.
Three sputum samples collected on three consecutive days were cultured and Burkholderia pseudomallei
) was isolated in all the cultures. Identification was done by standard techniques using Gram's staining and biochemical reactions.[6
] Antibiotic susceptibility was performed and interpreted as per Clinical Laboratory Standards Institute guidelines.[7
] Acid fast bacilli (AFB) staining by Ziehl-Neelsen's method was negative for all three sputum samples.[6
] Mycobacterium tuberculosis
was not isolated in any sputum culture.[6
] A bronchoscopy was done three days later, and B. pseudomallei
was isolated from culture of bonchoscopic aspirate. The aspirate was also positive for AFB and hence the specimen was inoculated in Lowenstein-Jensen media for Mycobacterial culture. Mycobacterium tuberculosis
was isolated in culture after five weeks of incubation.[6
] Blood culture was negative for both B. pseudomallei
and Mycobacterium tuberculosis
. As B. pseudomallei
was repeatedly isolated in different specimens - three sputum and one bronchoscopic aspirate, melidiosis was proven beyond doubt. Tuberculosis was established after Mycobacterium tuberculosis
was isolated from bronchoscopic aspirate culture.
For melioidosis, the patient was started on an intensive therapy with ceftazidime (two grams every six hours) and co-trimoxazole (sulphamethoxazole/trimethoprim, 800/160mg every 12 hours) for two weeks, followed by maintenance therapy with doxycycline (100mg every 12 hours) and co-trimoxazole (sulphamethoxazole/trimethoprim, 800/160mg every 12 hours) for three months.[1
] He was also administered standard multidrug therapy for tuberculosis for a period of six months consisting of Rifampicin (600mg/day), Isoniazid (300mg/day), Pyrazinamide (1.5 gram/day), ethambutol (800mg/day) for a period of two months followed by Rifampicin (600mg/day) and Isoniazid (300mg/day) for a period of four months.[1
] His liver function was monitored weekly for two months and later on for every 15 days. It was within normal limits throughout the course of treatment. The patient became symptom free within 10 days of commencement of therapy and recovered completely at the end of therapy.