Lobar Pneumonia in a Farmer Responded to Anti-melioidosis Antibiotics

A 46-year-old male, farmer, with no prior medical illness presented with a one-month history of intermittent right-sided pleuritic chest pain and productive cough. He complained of fever and breathlessness 3 days before current presentation to the district hospital. He denied any haemoptysis, night sweats, or contact with pulmonary tuberculosis. On examination, the vital signs were normal and lung auscultation revealed bronchial breath sounds and crepitation over the right upper zone. Chest radiograph demonstrated a right upper lobe consolidation with presence of air bronchogram and abdominal ultrasonography was normal. He was admitted for intravenous antibiotic therapy for a presumptive diagnosis of community-acquired pneumonia. He was initially treated with intravenous amoxicillin-clavulanic acid 1.2 g every 8 hours. Differential diagnosis of pulmonary tuberculosis was also considered but later ruled out as the sputum for direct smear microscopy, GenXpert and culture for Mycobacterium tuberculosis were negative. The melioidosis IgM (ELISA), multiple blood and sputum cultures were also negative. 
A PCR-based confirmatory test for melioidosis was however not available at our setting. In the ward, he continued to have persistent fever and repeated chest radiograph after 1 week of antibiotic showed worsening of right upper lobe consolidation. At this point in time, melioidosis was suspected due to the risk factor of farming. Antibiotic was then changed to intravenous ceftazidime 2 g every 6 hours. The patient responded positively as evidenced by the resolution of fever and respiratory symptoms, and repeated chest radiograph showed improving consolidation at 2 weeks. He was discharged after completing a 2-week course of intravenous ceftazidime, and simultaneously started on oral trimethoprim-sulfamethoxazole as eradication therapy. Upon review in the outpatient clinic 6 weeks later, chest radiograph showed marked improvement with minimal residual right upper lobe consolidation. He was clinically well and did not show any symptoms of relapse. He was planned for eradication therapy of 20 weeks’ duration.

A 46-year-old male, farmer, with no prior medical illness presented with a onemonth history of intermittent right-sided pleuritic chest pain and productive cough. He complained of fever and breathlessness 3 days before current presentation to the district hospital. He denied any haemoptysis, night sweats, or contact with pulmonary tuberculosis. On examination, the vital signs were normal and lung auscultation revealed bronchial breath sounds and crepitation over the right upper zone. Chest radiograph demonstrated a right upper lobe consolidation with presence of air bronchogram and abdominal ultrasonography was normal. He was admitted for intravenous antibiotic therapy for a presumptive diagnosis of community-acquired pneumonia. He was initially treated with intravenous amoxicillin-clavulanic acid 1.2 g every 8 hours.
Differential diagnosis of pulmonary tuberculosis was also considered but later ruled out as the sputum for direct smear microscopy, GenXpert and culture for Mycobacterium tuberculosis were negative. The melioidosis IgM (ELISA), multiple blood and sputum cultures were also negative.
A PCR-based confirmatory test for melioidosis was however not available at our setting. In the ward, he continued to have persistent fever and repeated chest radiograph after 1 week of antibiotic showed worsening of right upper lobe consolidation. At this point in time, melioidosis was suspected due to the risk factor of farming. Antibiotic was then changed to intravenous ceftazidime 2 g every 6 hours. The patient responded positively as evidenced by the resolution of fever and respiratory symptoms, and repeated chest radiograph showed improving consolidation at 2 weeks. He was discharged after completing a 2-week course of intravenous ceftazidime, and simultaneously started on oral trimethoprim-sulfamethoxazole as eradication therapy. Upon review in the outpatient clinic 6 weeks later, chest radiograph showed marked improvement with minimal residual right upper lobe consolidation. He was clinically well and did not show any symptoms of relapse. He was planned for eradication therapy of 20 weeks' duration.
A 46-year-old male, farmer, with no prior medical illness presented with a one-month history of intermittent rightsided pleuritic chest pain and productive cough. He complained of fever and breathlessness 3 days before current presentation to the district hospital. He denied any haemoptysis, night sweats, or contact with pulmonary tuberculosis. On examination, the vital signs were normal and lung auscultation revealed bronchial breath sounds and crepitation over the right upper zone.
Chest radiograph demonstrated a right upper lobe consolidation with presence of air bronchogram (figure 1a), and abdominal ultrasonography was normal. He was admitted for intravenous antibiotic therapy for a presumptive diagnosis of community-acquired pneumonia. He was initially treated with intravenous amoxicillin-clavulanic acid 1.2 g every 8 hours. Differential diagnosis of pulmonary tuberculosis was also considered but later ruled out as the sputum for direct smear microscopy, GenXpert and culture for Mycobacterium tuberculosis were negative. The melioidosis IgM (ELISA), multiple blood and sputum cultures were also negative. A PCR-based confirmatory test for melioidosis was however not available at our setting. In the ward, he continued to have persistent fever and repeated chest radiograph after 1 week of antibiotic showed worsening of right upper lobe consolidation (figure 1b). At this point in time, melioidosis was suspected due to the risk factor of farming. Antibiotic was then changed to intravenous ceftazidime 2 g every 6 hours.
The patient responded positively as evidenced by the resolution of fever and respiratory symptoms, and repeated chest radiograph showed improving consolidation at 2 weeks (figure 1c). He was discharged after completing a 2-week course of intravenous ceftazidime, and simultaneously started on oral trimethoprim-sulfamethoxazole as eradication therapy. Upon review in the outpatient clinic 6 weeks later, chest radiograph showed marked improvement with minimal residual right upper lobe consolidation (figure 1d). He was clinically well and did not show any symptoms of relapse. He was planned for eradication therapy of 20 weeks' duration.  . Diagnosis of melioidosis in a resource-limited setting is extremely challenging due to lack of more sophisticated test, and the outcome is greatly dependent on the clinicians' experience and competence.
Ethical considerations: Written informed consent was obtained from the patient for publication of this case report.