|Year : 2018 | Volume
| Issue : 4 | Page : 229-232
Septicemic melioidosis: A forensic autopsy case report
Atif Shamsudin1, Heo Chong Chin2, Ahmad Hafizam Hasmi1, Hapizah Mohd Nawawi3
1 Department of Forensic Medicine, National Institute of Forensic Medicine, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
2 Department of Medical Microbiology and Parasitology, Faculty of Medicine, Selangor, Malaysia
3 Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
|Date of Web Publication||27-Dec-2018|
Prof. Hapizah Mohd Nawawi
Institute of Pathology, Laboratory and Forensic Medicine, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Jalan Hospital, 47000 Sungai Buloh, Selangor
Source of Support: None, Conflict of Interest: None
We report a 27-year-old male from Kuwait who died due to melioidosis, and the diagnosis was achieved after the deceased underwent postmortem examination at the Forensic Department, Kuala Lumpur Hospital. While the disease is endemic in Southeast Asia and Northern Australia, human melioidosis infection has yet been reported in Kuwait. He was initially diagnosed as acute gastroenteritis at a private clinic before being found dead at a hotel in Kuala Lumpur. The autopsy revealed positive findings of Burkholderia pseudomallei in the deceased's brain, lung, liver, and spleen as well as in the blood and cerebrospinal fluid culture. The deceased's death highlights the importance of early accurate diagnosis, the common manifestations, and the need of effective antibiotic treatment of septicemic melioidosis in high prevalent areas.
Keywords: Autopsy, Burkholderia pseudomallei, melioidosis, postmortem, septicemic
|How to cite this article:|
Shamsudin A, Chin HC, Hasmi AH, Nawawi HM. Septicemic melioidosis: A forensic autopsy case report. J Forensic Sci Med 2018;4:229-32
| Introduction|| |
Melioidosis is caused by the Gram-negative Burkholderia pseudomallei bacillus. It is an infectious disease associated with significant mortality. The disease is endemic in the region of Southeast Asia and Northern Australia.
Most cases of melioidosis occur following the exposure to contaminated soil or water though percutaneous inoculation. Inhalation through contaminated dust particles or water droplets is the second most common route of entry.
In general, symptoms appear 2–4 weeks after the exposure. Clinical presentations were classified into the following primary diagnostic groups: (1) pneumonia; (2) soft-tissue infections; (3) genitourinary infection; (4) osteomyelitis/septic arthritis; (5) neurological; (6) skin; and (7) no evident focus.
We have obtained ethics waiver since this is only a case study of postmortem examination, and no consent is required as it was performed according to the protocol of postmortem examination. All steps have been taken to ensure the confidentiality of the case with high educational value. This case report has been approved by the Ministry of Health Malaysia to be published in the journal (KKM.NIHSEC.800-4/4/1 Jld. 59(28)) on July 17, 2018.
| Case Report|| |
A 27-year-old male originated from Kuwait who has no known medical illness except a history of head injury in a vehicle accident in 2014. He went for a holiday in Langkawi on November 04, 2016 and he developed fever and vomiting on November 07, 2016 after consuming food in a restaurant. He sought treatment from a private clinic and was diagnosed by the doctor as acute gastroenteritis with dehydration. He was given Intravenous Maxolon and 1 pint of normal saline. The doctor advised him to seek further treatment at the hospital. However, the deceased did not go to the hospital. Instead, he stayed at a budget hotel in Kuala Lumpur before he succumbed to death in the morning of November 09, 2016. His body was then brought by the police to the Forensic Department of Kuala Lumpur Hospital on the same day of his death at 7:55 a.m. for postmortem examination.
Postmortem computed tomography scan examination
Bilateral dilatation of lateral ventricles was suggestive of mild-to-moderate hydrocephalus. Mild generalized cerebral edema was reported. There was neither intracranial bleed nor significant midline shift.
Subsegmental collapsed consolidative changes seen at the posterior segment of the right lower lobe associated with adjacent ground glass opacity. There are multiple ill-defined nodules involving both lobes varying in sizes [Figure 1]. There are also fibrotic changes at the apical region bi-apically.
|Figure 1: Postmortem computed tomography scan image showed multiple ill-defined nodules involving both lungs|
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Reverse hepato-spleno attenuation was suggestive of mild fatty liver. Liver is borderline enlarged, no obvious focal liver lesions. Liver span measures 15.2 cm.
Kidneys and spleen
There was no gross abnormality found in the kidneys and spleen.
The body was average built with normal body mass index. Whitish froth with blood-stained discharge was seen from the mouth and nose. Congestion can be observed over the upper chest and face with hypostasis over the back of the body. The presence of bruises over the left upper occipital area is consistent with that sustained from a fall.
Examination of the brain showed edematous and weighed 1560 g. Cut section of the brain demonstrated an enlarged left posterior horn of the lateral ventricle and right body of the lateral ventricle, and it was filled with cerebrospinal fluid [Figure 2].
Examination of the lungs revealed both lungs were congested and edematous. Right lung and left lung weighed 560 and 550 g, respectively. A well-defined consolidation can be felt over the right lower lobe, measuring 7 cm × 6 cm with surrounding area of hemorrhage. Cut section showed grayish parenchyma. However, no pus discharge was seen [Figure 3].
|Figure 3: The lung showing showed consolidation and revealed grayish parenchyma on the cut section|
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In the abdomen, positive findings can be detected in the spleen and kidneys. The spleen was enlarged, weighed 220 g, congested, and friable on manipulation. Both kidneys weighed 120 g each, and multiple foci of hemorrhage were observed within the medulla and cortex on cut section. The liver was grossly intact, weighed 1370 g with a smooth surface.
Blood and cerebrospinal fluid specimens were sent to the Pathology Department of Kuala Lumpur Hospital for bacterial culture analysis. Both specimens showed a positive culture of B. pseudomallei. Blood agar and MacConkey culture-medias were used in culturing the organisms.
Examination of brain tissue showed brain edema, area of gliosis, and localized area of mild perivascular lymphocytic cuffing [Figure 4].
|Figure 4: Microscopic examination of the brain showed brain edema, area of gliosis, and localized area of mild perivascular lymphocytic cuffing (H and E, ×200)|
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Examination of the kidney tissue exhibited acute tubular necrosis, Bowman's capsule, and tubules-contained red blood cells and this is suggestive of hematuria.
Multifocal microabscess can be seen in all lobes of the lungs and in liver tissue [Figure 5]a and [Figure 5]b.
|Figure 5: (a) Microscopic examination of the lung tissue showed hemorrhagic and necrotic area with neutrophilic infiltration (micro-abscess) (H and E, ×400). (b) Microscopic examination of the liver tissue showing showed foci of micro-abscess with adjacent microsteatosis (H and E, ×200)|
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Specimens that were sent to the Department of Chemistry, Malaysia, are as shown in [Table 1].
|Table 1: List of specimens sent to the Department of Chemistry, Malaysia|
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Results suggested that the deceased had taken some medications for his illness, and at the same time, he was consuming illicit drugs. However, there was no quantitative value for each drug detected to indicate whether the drugs were at lethal dose.
Cause of death
Cause of death was reported due to B. pseudomallei septicemia.
| Discussion|| |
It is a standard practice at the Forensic Department of Kuala Lumpur Hospital that every police case received for postmortem examination to be computed tomography (CT) scanned. This procedure renders a constructive idea to the pathologist regarding the possible causes of death as well as a specific area to look for during the autopsy. In the above case, CT images indicated the presence of brain edema and hydrocephalus, consolidation, and fibrotic changes in the lungs, and the findings were subsequently confirmed by gross examination during the autopsy.
A definitive diagnosis of melioidosis is arrived by culturing the organism from any clinical sample because the organism is never a part of the normal human flora. In the present case, the deceased blood and cerebrospinal fluid were positive for B. pseudomallei, the causative agent for meliodosis. The diagnosis is further strengthened by the characteristic findings of micro-abscess from lungs, liver, and spleen tissues microscopically.
The lung is one of the most common affected organs in melioidosis. For visceral organs, the most common affected is the spleen, followed by the liver and kidney. Cerebral melioidosis is a rare manifestation of the infection and may be associated with melioidosis at other sites in up to 10% of cases. The radiological features of cerebral melioidosis are variable but predominantly manifest as encephalitis or abscess formation. Initial CT may be normal. Subsequent findings, such as localized intracerebral edema, the mass effect on adjacent structures, and peripheral enhancement of abscess cavities, may be seen.
The uniqueness of this case is due to the brain involvement in melioidosis. The incidence of the central nervous system (CNS) involvement in melioidosis is 3% (14/540) according to the Darwin study. In a study of 91 patients (culture confirmed) from Malaysia, 2% had neurologic involvement. The pathogenesis of CNS melioidosis is postulated to be due to direct bacterial invasion or hematogenous spread to the brain.
Since the clinical presentation of melioidosis is not distinctive and may range from acute septicemia to a chronic suppurative disease, a high index of clinical suspicion is required. In disseminated infection, the patient may complain of fever, headache, stomach, or chest pain. Due to this perplexing clinical presentation, the doctor had misdiagnosed it as acute gastroenteritis. In addition, refusal of the deceased to seek further treatment had also contributed to his own death.
Although healthy people may get melioidosis, the major risk factors include (1) diabetes (2) liver disease (3) renal disease (4) thalassemia (5) cancer or another immune-suppressing condition not related to HIV, and (6) chronic lung disease. However, all of these risk factors were not detected in the deceased during the postmortem examination.
The autopsy was performed in Kuala Lumpur Hospital on a body of a citizen from Kuwait. Therefore, information regarding the past medical history or any comorbidities of the deceased was very limited.
| Conclusion|| |
Although uncommon, acute onset of neurological symptoms and signs should alert the physician to suspect and investigate for melioidosis, especially when the patient is originated from or had visited endemic and potentially endemic areas.
The drug of choice is ceftazidime for systemic melioidosis. Despite improvements in antibiotic therapy, melioidosis is still associated with a significant mortality attributable to severe sepsis and its complications. Studies exploring the role of preventative measures, earlier clinical identification, and better management of severe sepsis are required to reduce the burden of this disease.
The authors would like to thank the police from Tun. H. S Lee Police Station, Kuala Lumpur, especially Sergeant Zainuddin Md. Nor, for their assistance in investigating the case. The authors would also like to thank the Director General of Health Malaysia for his permission to publish this article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]