Disseminated melioidosis complicated by symmetrical peripheral gangrene and multi-organ failure: a case report
TL;DR
SPG is a rare but devastating complication of disseminated melioidosis that may result in permanent disability and prompt antimicrobial therapy, intensive organ support, source control, and early recognition of peripheral ischemia are important.
Abstract
Background Melioidosis, caused by Burkholderia pseudomallei, is a potentially fatal infection endemic to Southeast Asia and northern Australia. Disseminated disease with bacteremia and multifocal organ involvement carries high mortality, particularly among patients with diabetes mellitus (DM) and hazardous alcohol use. Symmetrical peripheral gangrene (SPG) is a rare complication that may result in permanent disability. Case presentation A 57-year-old man with poorly controlled type 2 DM, chronic alcohol use, and malnutrition presented with septic shock and acute hypoxemic respiratory failure. Imaging revealed cavitary pneumonia and abscesses involving the liver, kidney, and prostate. Two independently collected blood cultures and a prostatic abscess aspirate yielded B. pseudomallei, confirmed through a multistep microbiological workflow with final VITEK 2 identification. The patient required vasopressors, mechanical ventilation, continuous venovenous hemofiltration, intravenous meropenem, and image-guided drainage of the prostatic abscess. Distal cyanosis was present at admission and progressed to dry gangrene of multiple fingers and toes. The symmetric acral distribution and absence of major-vessel obstruction were clinically consistent with SPG. Recurrent hyperkalemia and renal dysfunction prevented continued trimethoprim-sulfamethoxazole therapy, necessitating six months of doxycycline plus amoxicillin-clavulanate. Secondary infection and osteomyelitis of the gangrenous digits required multiple amputations. At follow-up 11 months after completion of eradication therapy, there was no evidence of recurrent melioidosis. Conclusion SPG is a rare but devastating complication of disseminated melioidosis. Prompt antimicrobial therapy, intensive organ support, source control, and early recognition of peripheral ischemia are important. Even after survival and successful treatment, substantial long-term functional disability may persist.