Melioidosis Presenting as a Solitary Liver Abscess With Culture-Negative Septic Arthritis: A Case Report

Abstract

Melioidosis is an infection caused by Burkholderia pseudomallei with varied clinical manifestations, particularly in patients with diabetes mellitus. Hepatic involvement usually occurs as part of multifocal disease, while a solitary liver abscess is uncommon. We report a 49-year-old man with poorly controlled type 2 diabetes mellitus who presented with fever and right upper quadrant pain. Ultrasonography showed a right lobe liver abscess, and empirical treatment with ceftriaxone and metronidazole was started. Despite treatment, he developed persistent fever, increasing leukocytosis, hypotension, metabolic acidosis, altered mentation, and acute painful swelling of the left knee. Contrast-enhanced computed tomography showed a solitary multiloculated liver abscess measuring 5.3 × 3.8 × 3.2 cm with a honeycomb appearance. Percutaneous drainage was performed, and culture of the liver abscess grew Burkholderia pseudomallei. Ultrasound-guided aspiration of the knee yielded purulent hemorrhagic fluid with a leukocyte count of 35,000/mm³ and low glucose. Gram stain and culture of the joint fluid were negative, and the findings were considered consistent with culture-negative septic arthritis associated with melioidosis. The patient was treated with intravenous ceftazidime with marked clinical improvement within 36-48 hours, followed by oral trimethoprim-sulfamethoxazole eradication therapy. He remained clinically well at approximately one-year follow-up. This case highlights that melioidosis should be considered in patients with diabetes with a solitary liver abscess, particularly when there is poor response to empirical therapy and evidence of another infective focus.