A 42-year-old Sri Lankan man presented to the Colombo North Teaching Hospital, Ragama, Sri Lanka (CNTH) with a febrile illness of 6 days, accompanied by headache and constitutional symptoms. He was a grocer from Minuwangoda, a suburban area in the Western Province situated 44 km from Colombo. He was initially investigated and treated at a regional hospital for 4 days, and was transferred to the CNTH for specialized care. He gave a history of type 2 diabetes mellitus for 5 years without microvascular or macrovascular complications, and was a nonsmoker and a teetotaler. There were no specific symptoms suggesting a source of infection such as cough, abdominal pain, urinary symptoms, etc. He was febrile with a temperature of 39.10 C, and examination of the heart, lungs and abdomen was unremarkable. There was no papilloedema, focal neurological signs, pyramidal signs or neck stiffness. Initial laboratory work up revealed features of a bacterial infection, with neutrophil leukocytosis and elevated inflammatory markers (erythrocyte sedimentation rate – 101 mm/1st hour, C-reactive protein - 220 mg/dl). Initial blood cultures done at the regional hospital had yielded an isolate, which was reported as a Pseudomonas species; this was sensitive to ceftazidime, imipenem and meropenem and resistant to gentamicin and ceftriaxone. Other basic laboratory investigations including renal and liver function tests, electrolyte panel and urinalysis were normal. Chest x-ray and ultrasound scan of the abdomen were normal, and the trans-thoracic 2-D echo did not show any vegetations. As the unusual antibiotic sensitivity pattern suggested the possibility of melioidosis, blood was sent for serological testing to a specialized Melioidosis Research Laboratory at the Faculty of Medicine, University of Colombo.\nHe had been initially treated with intravenous ceftriaxone, and later with ceftazidime according to the antibiotic sensitivity pattern. Although the frequency and intensity of fever spikes reduced with treatment, he continued to have low grade fever and complain of anorexia, malaise and lethargy. On the 4th day after admission to the CNTH (day 10 of the illness), he developed simple partial seizures involving the left lower limb, progressing to persistent numbness of the left side of the body. An urgent CT scan of the head revealed a subdural collection over the right fronto-parietal region with gas locules and obliteration of sulci and gyri, without definite evidence of abscess formation (Fig. ). Contrast enhanced MRI scan of the brain demonstrated a subdural collection in the right fronto-temporo-parietal region with possible abscess formation in the right parietal region (Fig. ). Seizures were treated with oral sodium valproate and phenytoin sodium. He was referred for neurosurgical opinion, and the subdural collection was managed conservatively. Results of the indirect hemagglutination assay (IHA) for melioidosis antibodies were received on the following day; an antibody titre of more than 1/10,240 was strongly suggestive of an acute infection with Burkhoderia pseudomallei and a diagnosis of cerebral melioidosis was made.\nAntibiotics were changed to intravenous meropenem and oral trimethoprim/sulfamethoxazole (Co-trimoxazole/TMP-SMX). Initial intensive therapy with these antibiotics was continued for 8 weeks, until clinical improvement was evident with resolution of inflammatory markers and radiological improvement confirmed by repeat MRI scan of the brain. (Fig. ) Repeat blood cultures were sterile after 2 weeks of treatment with antibiotics. There were no further seizures, and the fever and the neurological symptoms resolved completely. He was discharged home with oral TMP-SMX and doxycycline, which were continued for 6 months, and the antiepileptics were gradually tailed off. At 6 months follow up he was asymptomatic. (Fig. ).
A 53-year-old gentleman, known diabetic of 8 years duration presented with a pain in both lower limbs of 15 days duration and weakness in the form of ascending quadriparesis involving proximal followed by distal group of muscles of 12 days duration. There were no cranial nerve and respiratory symptoms. There was history of malaise and low grade fever preceding this illness.\nOn examination at admission, vital signs were normal. General physical examination was normal. Higher mental functions and cranial nerve examination were normal. There was hypotonia in all four limbs with Medical research council (MRC) power of grade 4/5. The deep tendon reflexes were absent and he had bilateral flexor plantar response. Cerebrospinal fluid examination revealed albumino-cytological dissociation (Glucose 70 mg%, protein 88 mg%, no cells). Nerve conduction studies were suggestive of demyelinating polyradiculoneuropathy. He was detected to be HBs Ag positive and was seronegative for human immunodeficiency virus infection. Apart from elevated glycosylated hemoglobin A1C level of 7.8%, serum biochemical parameters including potassium levels were normal. He had neutrophilic leukocytosis (13,400/cmm, 88% neutrophils), blood cultures were sent and was empirically started on ceftriaxone. IV immunoglobulins of 0.40 g/kg/day were given for 5 days. During the course of the hospital stay, his blood sugars were kept under control with insulin.\nOn 2nd day of admission, patient developed bilateral facial weakness, power deteriorated to MRC grade 3/5. After 4 days of treatment, the patient developed respiratory distress requiring ventilatory support. Arterial blood gases report showed metabolic acidosis with raised lactate levels and hypoxia. Later, patient developed refractory septic shock and succumbed to death. Cultures grew B. pseudomallei and the diagnosis of melioidiosis presenting as GBS on a background of diabetes mellitus was considered.