Unveiling a Medical Mystery: A Compelling Case Presentation
In February 2006, a vibrant and previously healthy 58-year-old Sinhalese woman arrived at our hospital with a perplexing set of symptoms. Her recent experiences included fluctuating fever, pounding headaches, decreased appetite, weight loss, a persistent dry cough, and painful joint inflammation lasting for 5 weeks. Before this episode, she had no medical issues, and her family had no history of chronic ailments. As an avid gardener and a dedicated homemaker, she had not ventured into the forests or worked in paddy fields. She led a healthy lifestyle free from alcohol or smoking.
Initially, she was admitted to another medical center, where she underwent a series of tests and received broad-spectrum antibiotics. Despite her persisting fever and markedly elevated levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), the elusive diagnosis of tuberculosis remained unconfirmed. Instead of showing signs of improvement while on antituberculous medication, her condition worsened. Disturbingly, she developed tender lumps over the right temporal area within a week, followed by another on the anterior aspect of her left thigh five days later. Frustrated with the lack of progress, she left the first hospital against medical advice and sought refuge in the care of Teaching Hospital Peradeniya (THP).
Upon admission to THP, her feeble appearance and distressing symptoms raised concern. She displayed a tender lump resembling an abscess on the right temporal area and additional lumps on the anterior aspect of her left thigh. Further examination revealed inflamed and swollen knee and wrist joints, accompanied by an erythematous rash on both shins, resembling erythema nodosum. Her pulse rate was elevated at 110 beats per minute, and her blood pressure measured 100/65 mmHg. The examinations of her respiratory and abdominal systems yielded normal results. Though she remained conscious and rational with no neck stiffness, her deteriorating condition prompted expedited investigation.
At this crucial juncture, blood samples were collected for essential tests and culture. The diagnostic needle aspirates from the cystic lumps and knee joint effusions were purulent and forwarded for bacteriological analysis. Under strict aseptic conditions, blood samples were drawn in three separate intervals over 30 minutes and placed in standard blood culture bottles. Similarly, knee joint and skin lump aspirates were carefully collected into separate culture containers. These samples were promptly transported to the hospital’s microbiology laboratory, where a consultant microbiologist carried out the cultures. Meanwhile, pending further investigation, the patient received intravenous (IV) co-amoxiclav (a combination of amoxicillin and clavulanic acid).
On the fifth day of her hospitalization, the patient’s condition deteriorated drastically. She experienced drowsiness and focal seizures, mainly affecting her right upper and lower limbs. The seizures lasted approximately two minutes. Her Glasgow Coma Scale (GCS) score dropped to 12/15, but she retained voluntary movement in all her limbs and exhibited normal deep tendon reflexes, with the exception of an upgoing plantar response. No signs of neck stiffness, positive Kernig sign, or focal neurological deficits were detected. Her blood pressure remained alarmingly low at 90/50 mmHg, while her respiratory rate rose to 30 breaths per minute, accompanied by bibasal crepitations. Swollen and tender knee joints with bilateral effusions persisted. The medical team suspected cerebral abscesses and promptly transferred her to the intensive care unit (ICU).
The urgent contrast-enhanced computed tomography (CT) scan of her brain uncovered a well-defined cystic mass situated outside the skull vault in the right temporal region, displaying contrast-enhanced changes in the adjacent brain matter. Furthermore, a 12-lead electroencephalogram (EEG) detected a theta-wave focus over the right temporal area, occasionally accompanied by epileptiform discharges, signifying structural brain damage. Ultrasound examinations of her abdomen and an echocardiogram yielded normal results. Her white blood cell count stood at 3.3 × 10^9/L, with neutrophils accounting for 83% and lymphocytes for 12%. ESR registered 120 mm in the first hour, and CRP levels measured 192 mg/L. Her chest x-ray revealed multiple ill-defined cystic areas located peripherally in both lung fields, particularly concentrated at the lung bases, thus suggesting the presence of multiple lung abscesses. The blood culture, knee joint aspirate, and skin lump aspirates all grew B. pseudomallei, a diagnosis confirmed by both local and international reference laboratories. Melioidosis was the final diagnosis, and the treatment promptly commenced.
Following the confirmation of melioidosis, the patient’s antibiotic regimen was revised. She began receiving IV meropenem (1 g every 8 hours) for eight days, which was later switched to IV imipenem (500 mg every 6 hours) based on the bacterial isolate’s antibiotic sensitivity pattern. Two additional antibiotics, IV ciprofloxacin (400 mg every 12 hours) and IV ceftazidime (2 g every 6 hours), were incorporated into her treatment plan simultaneously. Gradually, her overall condition improved, and her fever subsided within a few days. Although all three antibiotics were administered for a total of 30 days, they were later replaced with an oral antibiotic course. This consisted of cotrimoxazole (1920 mg twice daily) and doxycycline (100 mg twice daily) for an additional 20 weeks. Sodium valproate (200 mg thrice daily) proved effective in controlling her seizures. During her follow-up visits, chest x-rays, ESR (50 mm/h), CRP (0.7 mg/dl), liver and renal profiles indicated progressive improvement. Her HIV screening yielded negative results, and her blood sugar and hemoglobin A1c levels remained within the normal range. A repeat EEG conducted three months later showed normal results, leading to a gradual tapering of sodium valproate. After completing six months of antibiotic treatment, her ESR measured 12 mm in the first hour, her CRP dropped below 6 mg/L, and all her other biochemical parameters returned to normal. She was advised to return annually to our hospital for follow-up screenings that include ESR and CRP measurements. Astonishingly, she has remained free from any recurrence of the disease for the past 13 years, continuing to enjoy excellent health.
Subsequently, an investigation was launched into the origin of her infection. The patient recalled an incident that may have triggered her illness. A few days before falling ill, she came into contact with soil. The footpath leading to her home ended in a side drain that had been dug up and subsequently filled with mud and soil. Without thinking twice, she used her bare feet to clear the path, unwittingly exposing herself to the lurking danger.
This eye-opening case serves as a stark reminder of the importance of prompt diagnosis, adequate treatment, and cautious contact with the environment. To learn more about traveling safely in Sri Lanka, visit DHPL Travels and embark on your next adventure with peace of mind.