Melioidosis of the Musculoskeletal System

Abstract

Objective: Recent studies indicate that India is an endemic region for Burkholderia pseudomallei infection. We aimed to describe the clinical presentation of B. pseudomallei infection of the musculoskeletal system and summarise the various treatment modalities used in our clinical practice.

Subjects and methods: Patients with confirmed microbiological diagnosis of B. pseudomallei infection involving the musculoskeletal system treated from January 2007 to December 2016 with a minimum follow-up of 1 year were included. A retrospective review of medical records was carried out and patients' demographic data, co-morbidities, clinical presentation, and details of medical and surgical treatment were documented.

Results: Of 342 patients diagnosed with B. pseudomallei infection, 37 (9.2%) had musculoskeletal involvement; 26 patients (23 males) followed up for at least a year were included in the study. Four patients (15%) had multisystem involvement and 10 (37%) had multiple musculoskeletal foci of infection; 15 patients (58%) had osteomyelitis, 10 (38%) had septic arthritis with or without osteomyelitis, and 1 patient (4%) presented with only soft tissue abscess. All patients required surgical intervention in addition to medical management. Surgical treatment varied from soft tissue abscess drainage, arthrotomy for septic arthritis, decompression and curettage for osteomyelitis, and/or use of antibiotic (meropenem or ceftazidime)-loaded polymethylmethacrylate bone cement for local drug delivery. At final follow-up (average: 37 months, range: 12-120), all patients were disease free.

Conclusion: We found the rate of musculoskeletal involvement in B. pseudomallei infection to be 9.2%. Appropriate surgical treatment in addition to medical management resulted in resolution of disease in all our patients.

Keywords: Burkholderia psuedomallei; Melioidosis; Musculoskeletal system.

Fig. 1

Comorbidities in patients with melioidosis. HTN, hypertension; CRF, chronic renal failure.

Fig. 2

Preoperative anteroposterior (a) and lateral (b) radiographs and STIR sagittal MRI (c) of the right femur of a 38-year-old man (patient 13, Table 1) with right proximal thigh pain and swelling for 3 weeks associated with low-grade intermittent fever. He was diagnosed with acute chronic osteomyelitis, which was microbiologically confirmed as Burkholderia psuedomallei infection. A year prior to presentation, he was diagnosed and treated elsewhere for Pseudomonas osteomyelitis.

Fig. 3

Postoperative anteroposterior (a) and lateral (b) radiographs of a 38-year-old man (patient 13, Table 1) with melioidosis of the right proximal femur treated through decompression, curettage, antibiotics (meropenem), and bone cement (polymethylmethacrylate)-coated K-nail insertion. There was clinical resolution of the infection, and the patient underwent removal of the implant 4 months later. Anteroposterior (c) and lateral (d) radiographs at the final follow-up 2 years later.

Fig. 4

Anteroposterior (a) and lateral (b) radiographs of a 36-year-old man (patient 16, Table 1) with melioidosis presenting with fever and painful swelling for 14 weeks and right ankle for 3 weeks. Radiographs showed a permeative pattern of bone destruction in the left distal femur and proximal tibia. STIR coronal (c) and sagittal (d) MRI sections showed multiple interosseous collections in the medullary canal of the distal femur and proximal tibia, consistent with infective pathology. He underwent decompression and curettage of the left distal femur and proximal tibia and arthrotomy of the right ankle joint. Five weeks after index surgery, the bone defect was packed with the antibiotic bone cement (ceftazidime), and a soft tissue cover was provided by raising a medial gastrocnemius flap and split thickness skin graft.

Fig. 5

Anteroposterior (a) and lateral (b) radiographs of a 36-year-old man (patient 16, Table 1) with melioidosis that were taken at the final follow-up (30 months) showing an antibiotic bone cement (polymethylmethacrylate) spacer in the bone defect of the left proximal tibia. The patient had no recurrence at final follow-up.