Merck Manual

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(Whitmore Disease)


Larry M. Bush

, MD, FACP, Charles E. Schmidt College of Medicine, Florida Atlantic University;

Maria T. Vazquez-Pertejo

, MD, FACP, Wellington Regional Medical Center

Reviewed/Revised Apr 2022 | Modified Sep 2022

Melioidosis is an infection caused by the gram-negative bacterium Burkholderia (formerly Pseudomonas) pseudomallei. Manifestations include pneumonia, septicemia, and localized infection in various organs. Diagnosis is by staining and culture. Treatment with antibiotics, such as ceftazidime, is prolonged.

Burkholderia pseudomallei can be isolated from soil and water and is endemic in Southeast Asia; Australia; Central, West, and East Africa; India; the Middle East; and China. The risk of contracting melioidosis is highest for adventure travelers, ecotourists, military personnel, construction workers, miners, and other people whose contact with contaminated soil or water may expose them to the bacteria in an endemic area.

Humans may contract melioidosis by contamination of skin abrasions or burns, ingestion, or inhalation but not directly from infected animals or other humans.

In endemic areas, melioidosis is likely to occur in patients with

Symptoms and Signs of Melioidosis

Melioidosis may manifest acutely or remain latent for years after an inapparent primary infection. Case fatality is < 10%, except in acute septicemic melioidosis, which is frequently fatal.

Acute pulmonary infection is the most common form. It varies from mild to overwhelming necrotizing pneumonia. Onset may be abrupt or gradual, with headache, anorexia, pleuritic or dull aching chest pain, and generalized myalgia. Fever is usually > 39° C. Cough, tachypnea, and rales are characteristic. Sputum may be blood-tinged. Chest x-rays usually show upper lobe consolidation, frequently cavitating and resembling tuberculosis. Nodular lesions, thin-walled cysts, and pleural effusion may also occur. The white blood cell count ranges from normal to 20,000/mcL (20 × 109/L).

Acute septicemic infection begins abruptly, with septic shock Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more and multiple organ involvement manifested by disorientation, extreme dyspnea, severe headache, pharyngitis, upper abdominal colic, diarrhea, and pustular skin lesions. High fever, hypotension, tachypnea, a bright erythematous flush, and cyanosis are present. Muscle tenderness may be striking. Signs of arthritis or meningitis sometimes occur. Pulmonary signs may be absent or may include rales, rhonchi, and pleural rubs.

Localized suppurative infection can occur in almost any organ but is most common at the site of inoculation in the skin (or lungs) and associated lymph nodes. Typical metastatic sites of infection include the liver, spleen, kidneys, prostate, bone, and skeletal muscle. Acute suppurative parotiditis is common among children in Thailand. Patients may be afebrile.

Diagnosis of Melioidosis

  • Staining and culture

B. pseudomallei can be identified in exudates by methylene blue or Gram stain and by culture. Blood cultures often remain negative except when there is marked bacteremia (eg, in septicemia). Serologic assays are often unreliable in endemic areas because positive results may be due to previous infection.

Chest x-rays usually show irregular, nodular (4 to 10 mm) densities but may also show lobar infiltrates, bilateral bronchopneumonia, or cavitary lesions.

Ultrasonography or CT of the abdomen and pelvis should probably be done to detect abscesses, which may be present regardless of the clinical presentation. The liver and spleen may be palpable. Liver tests, aspartate aminotransferase (AST), and bilirubin are often abnormal. Renal insufficiency and coagulopathy may be present in severe cases. The white blood cell count is normal or slightly increased.

Treatment of Melioidosis

  • For symptomatic patients, several weeks of IV antibiotics followed by a prolonged course of an oral drug

Asymptomatic melioidosis needs no treatment.

Symptomatic patients are given ceftazidime 30 mg/kg IV every 6 hours for 2 to 4 weeks (imipenem, meropenem, and piperacillin are acceptable substitutes), then oral antibiotics (one double-strength tablet of trimethoprim/sulfamethoxazole [TMP/SMX] 2 times a day or doxycycline 100 mg 2 times a day) for 3 to 6 months. In children < 8 years and pregnant women, amoxicillin/clavulanate 25/5 mg/kg 3 times a day is used instead of doxycycline.

Key Points

  • Melioidosis is acquired by skin contact, ingestion, or inhalation; it is not acquired directly from infected animals or people.

  • The most common manifestation is an acute pulmonary infection (occasionally severe), but suppurative lesions may occur in the skin and/or many other organs; septicemia, which has high mortality, may result.

  • Diagnose using staining and culture; blood cultures are done but often are negative except in severe septicemia.

  • Treat symptomatic patients with IV ceftazidime followed by a prolonged course of oral TMP/SMX or doxycycline; in children < 8 years and pregnant women, use amoxicillin/clavulanate instead of doxycycline.

Drugs Mentioned In This Article

Drug Name Select Trade
Ceptaz, Fortaz, Tazicef, Tazidime
PROVAYBLUE, Urolene Blue
Primsol, Proloprim, TRIMPEX
Acticlate, Adoxa, Adoxa Pak, Avidoxy, Doryx, Doxal, Doxy 100, LYMEPAK, Mondoxyne NL, Monodox, Morgidox 1x, Morgidox 2x , Okebo, Oracea, Oraxyl, Periostat, TARGADOX, Vibramycin, Vibra-Tabs
Amoxil, Dispermox, Moxatag, Moxilin , Sumox, Trimox
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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