Skip to main page content

• HOME
• Current Issue
• Archive
• Alerts
• About ASM
• Contact us
• Tech Support
• Journals.ASM.org

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints and Permissions Copyright Information Books from ASM Press MicrobeWorld Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Barth, A. L. Articles by de Andrade Marques, E. Search for Related Content PubMed PubMed Citation Articles by Barth, A. L. Articles by de Andrade Marques, E.

 Previous Article  |  Next Article 

Journal of Clinical Microbiology, December 2007, p. 4077-4080, Vol. 45, No. 12
0095-1137/07/$08.00+0     doi:10.1128/JCM.01386-07
Copyright © 2007, American Society for Microbiology. All Rights Reserved.

CASE REPORT

Cystic Fibrosis Patient with Burkholderia pseudomallei Infection Acquired in Brazil

Afonso Luís Barth,^1* Fernando Antonio de Abreu e Silva,² Anneliese Hoffmann,² Maria Izolete Vieira,¹ Alexandre Prehn Zavascki,¹ Alex Guerra Ferreira,³ Luiz Gonzaga da Cunha Jr.,³ Rodolpho Mattos Albano,⁴ and Elizabeth de Andrade Marques³

Unidade de Microbiologia e Biologia Molecular, Serviço de Patologia Clínica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,¹ Setor de Pneumologia Pediátrica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,² Departamento de Microbiologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil,³ Departamento de Bioquímica, Instituto de Biologia, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil⁴

Received 10 July 2007/ Returned for modification 20 August 2007/ Accepted 27 September 2007

Top ABSTRACT CASE REPORT REFERENCES

 
Burkholderia pseudomallei is rarely isolated from cystic fibrosis patients outside known areas of endemicity. We report the recovery of B. pseudomallei from the sputum of a cystic fibrosis patient who lives in Brazil. We highlight the importance of careful attention to unusual nonfermentative gram-negative rods in cystic fibrosis patients.

Top ABSTRACT CASE REPORT REFERENCES

 
The patient was a 17-year-old female patient with cystic fibrosis (CF) who lives in Barra dos Bugres, Mato Grosso do Sul, a region located in the tropical area of Brazil, and has never traveled outside the country. This patient has been followed at the Hospital de Clínicas de Porto Alegre, a CF reference center in Porto Alegre, south Brazil.

Despite the diagnosis of CF-related diabetes associated with chronic lung infection by methicillin-susceptible Staphylococcus aureus and Pseudomonas aeruginosa, her pulmonary disease was well controlled until 2003. The patient had normal lung function (forced expiratory volume in the first second [FEV1] of 102% of predicted) and only minor bronchiectactic changes shown by high-resolution chest computer tomography (CT). After 2004, her pulmonary condition progressively deteriorated, as she presented with frequent respiratory exacerbations and recurrent radiological changes, as well as right upper lobe bronchiectasis. During this period, a nonfermentative gram-negative rod was recovered from her sputum, which was not identified using a semiautomated system (mini-API, ID 32 GN card; bioMeriéux, Marcy l'Etoile, France).

In July 2005, due to an episode of respiratory exacerbation the patient was admitted to hospital again, when a sputum sample was collected for bacteriological examination. The sputum sample was inoculated on MacConkey agar (bioMérieux), chocolate agar (bioMérieux), 5% sheep blood agar (bioMérieux), mannitol salt agar (Oxoid, Basingstoke, United Kingdom), and Burkholderia cepacia selective agar (BCSA [Oxoid]) which were incubated at 37°C. After 48 h, dry colonies were observed on the MacConkey, blood, and chocolate agars. Colonies with the same dried appearance and a pinkish color were also observed on the BCSA. This isolate proved to be a nonfermentative gram-negative rod that was submitted to further identification using the mini-API (bioMérieux) semiautomated system with the ID32GN card. The mini-API suggested the isolate was Burkholderia pseudomallei, with an excellent level of identification (99%), and the results of other phenotypic tests were also consistent with B. pseudomallei (Table 1). Species identification was also confirmed by PCR amplification of the 16S rRNA gene using primers 27FB (9) and 1492RB (5). The amplicon (1,200 bp) was directly sequenced, and a good-quality sequence of 800 bp was analyzed. The sequence was used for a BLAST search against the GenBank database, and the best match obtained was with B. pseudomallei (gi 33286699), with 99% identity. The clinical condition of the patient improved after a 3-week course of piperacillin-tazobactam and tobramycin.

View this table: [in this window] [in a new window]

TABLE 1. Characteristics of Burkholderia pseudomallei isolated from a Brazilian CF patient

In April 2006, the patient was readmitted for an episode of respiratory exacerbation and B. pseudomallei was again isolated from her sputum. After a 3-week course of meropenem, ceftazidime, amikacin, and trimethoprim-sulfamethoxazole her clinical and radiological status improved.

A 2-year follow-up showed that B. pseudomallei was repeatedly recovered from her sputum, the patient having had frequent pulmonary exacerbations requiring hospital admissions and showing gradual deterioration of lung function (FEV1 fell from 102% of predicted to 60% of predicted).

The serum of the patient was tested by enzyme-linked immunosorbent assay against B. pseudomallei by the Health Protection Agency, Colindale, United Kingdom, on two occasions, and immunoglobulin G titers were 2,000 (August 2005) and 1,000 (April 2006).

CF is the most common life-threatening genetic disorder among Caucasians. The main cause of morbidity and mortality in CF is respiratory disease associated with chronic bacterial infection, and the most prevalent bacterial pathogens associated with this are S. aureus, P. aeruginosa, and the Burkholderia cepacia complex (11).

The aerobic, nonfermentative, gram-negative, soil-dwelling rod B. pseudomallei is the causative agent of melioidosis, a severe disease endemic in areas of Southeast Asia and northern Australia (2). However, sporadic cases have been reported in west and east Africa, the Caribbean, Central and South America, and the Middle East (2). The first reported case of meliodosis in Brazil was in 2003 in the northeast state of Ceará (12). Afterwards, a few other cases, in non-CF patients, were described in this region (15).

B. pseudomallei has only rarely been described in CF patients, most cases occurring after traveling to a region of endemicity (Table 2). In this article, we have described a case of B. pseudomallei respiratory infection acquired by a CF patient in Brazil. To our knowledge, this is the first description of B. pseudomallei in a CF patient acquired outside the known regions of endemicity. Diabetes mellitus, a recognized risk factor for melioidosis (2), was also present in our patient, and this might have contributed to B. pseudomallei acquisition.

View this table: [in this window] [in a new window]

TABLE 2. Burkholderia pseudomallei in cystic fibrosis patients reported in the literature

Melioidosis usually presents as a febrile illness, ranging from an acute fulminant sepsis to a chronic debilitating localized infection (2). Most CF patients with B. pseudomallei present with pulmonary exacerbations (Table 2), which are indistinguishable from those due to other common CF organisms. Only one patient was reported to have developed severe pulmonary sepsis and died (14), but another five patients presented with acute pulmonary infections and recovered clinically (6, 14, 18). Most of the described patients have also experienced progressive clinical deterioration after the isolation of B. pseudomallei, although a few have presented no clinical change in the course of the disease (6, 14). In this case report, B. pseudomallei was detected during an episode of clinical exacerbation of the respiratory disease, although one could speculate that this organism might have already been present in the patient's airways. B. pseudomallei has been repeatedly recovered from our patient's sputum over a period of 2 years.

Due to the difficulty in identifying B. pseudomallei, it is likely that reported cases of this organism in CF patients could represent an underestimation of the real incidence of this infection since many laboratories have no experience in recognizing this microorganism (3, 7). Considering that the isolation of B. pseudomallei from CF patients may have significant therapeutic and prognostic implications, as well as considerable safety precautions, it is important to precisely identify unusual nonfermentative gram-negative organisms repeatedly recovered from these patients, even from regions where the organisms are nonendemic. Some biochemical reactions are useful to differentiate B. pseudomallei from similar nonfermentative rods, like Pseudomonas stutzeri and the B. cepacia complex isolates. Whereas B. pseudomallei produces gas from nitrate and is arginine dihydrolase positive, most isolates of the B. cepacia complex are negative for both characteristics. P. stutzeri is negative for arginine dihydrolase, glucose oxidation, and gelatin hydrolysis (13). However, it has been shown (8, 10) that the accuracy for the identification of B. pseudomallei by commercial methods is system dependent. While a few systems are able to identify B. pseudomallei with very high accuracy, other systems present very low accuracy or do not have B. pseudomallei in their database. The latter systems misidentified B. pseudomallei as B. cepacia with a high confidence value (95 to 99%). Therefore, we understand that an isolate outside the areas of endemicity suspected of being B. pseudomallei according to any phenotypic method should be also confirmed by genetic techniques (e.g., 16S rRNA sequencing).

 
We thank Tyrone L. Pitt (Health Protection Agency, Colindale, United Kingdom) for performing the enzyme-linked immunosorbent assay to identify the antibody levels against B. pseudomallei in the serum of the patient and for helpful comments.

 
* Corresponding author. Mailing address: Hospital de Clínicas de Porto Alegre, Unidade de Microbiologia e Biologia Molecular, Rua Ramiro Barcellos 2350, Porto Alegre—RS, Brazil 90035-903. Phone and fax: 51 21018607. E-mail: albarth{at}hcpa.ufrgs.br

Published ahead of print on 17 October 2007.

Top ABSTRACT CASE REPORT REFERENCES

 

1
1. Asiah, K., Y. A. Hanifa, M. Z. Norzila, L. Hasniah, and A. Rusanida. 2006. Unrecognised infection in a cystic fibrosis patient. J. Paediatr. Child Health 42:217-218.[CrossRef][Medline]
2
2. Cheng, A. C., and B. J. Currie. 2005. Melioidosis: epidemiology, pathophysiology, and management. Clin. Microbiol. Rev. 18:383-416.[Abstract/Free Full Text]
3
3. Dance, D. A. B. 1991. Melioidosis: the tip of the iceberg? Clin. Microbiol. Rev. 4:52-60.[Abstract/Free Full Text]
4
4. Dance, D. A. B., M. D. Smith, M. H. Aucken, and T. L. Pitt. 1999. Imported melioidosis in England and Wales. Lancet 353:208.[Medline]
5
5. Hirashi, A. 1992. Direct automated sequencing of 16S rDNA amplified by polymerase chain reaction from bacterial cultures without DNA purification. Lett. Appl. Microbiol. 15:210-213.[Medline]
6
6. Holland, D. J., A. Wesley, D. Drinkovic, and B. J. Currie. 2002. Cystic fibrosis and Burkholderia pseudomallei: an emerging problem? Clin. Infect. Dis. 35:138-140.
7
7. Inglis, T. J. J., A. Merritt, G. Chidlow, M. Aravena-Roman, and G. Harnett. 2005. Comparison of diagnostic laboratory methods for identification of Burkholderia pseudomallei. J. Clin. Microbiol. 43:2201-2206.[Abstract/Free Full Text]
8
8. Koh, T. H., L. S. Y. Nong, J. L. Foon Ho, L.-H. Sng, G. C. Y. Wang, and R. V. Tzer Pin Lin. 2003. Automated identification systems and Burkholderia pseudomallei. J. Clin. Microbiol. 41:1809. (Letter.)[Free Full Text]
9
9. Lane, D. J. 1991. 16S/23S rRNA sequencing, p. 115-175. In E. Stackebrandt and M. Goodfellow (ed.), Nucleic acid techniques in bacterial systematics. Wiley, New York, NY.
10
10. Lowe, P., C. Engler, and R. Norton. 2002. Comparison of automated and nonautomated systems for identification of Burkholderia pseudomallei. J. Clin. Microbiol. 40:4625-4627.[Abstract/Free Full Text]
11
11. Lyczak, J. B., C. L. Cannon, and G. B. Pier. 2002. Lung infections associated with cystic fibrosis. Clin. Microbiol. Rev. 15:194-222.[Abstract/Free Full Text]
12
12. Miralles, I. S., C. Maciel Mdo, M. R. Angelo, M. M. Gondini, L. H. Frota, C. M. dos Reis, and E. Hofer. 2004. Burkholderia pseudomallei: a case report of a human infection in Ceara, Brazil. Rev. Inst. Med. Trop. Sao Paulo 46:51-54.[Medline]
13
13. Murray, P. R., E. J. Baron, J. H. Jorgensen, A. Pfaller, and R. H. Yolken (ed.). 2003. Manual of clinical microbiology, 8th ed. ASM Press, Washington, DC.
14
14. O'Carroll, M. R., T. J. Kidd, C. Coulter, H. V. Smith, B. R. Rose, C. Harbour, and S. C. Bell. 2003. Burkholderia pseudomallei: another emerging pathogen in cystic fibrosis. Thorax 58:1087-1091.[Abstract/Free Full Text]
15
15. Rolim, D. B., D. C. Vilar, A. Q. Sousa, I. S. Miralles, D. C. de Oliveira, G. Harnett, L. O'Reilly, K. Howard, I. Sampson, and T. J. Inglis. 2005. Melioidosis, northeastern Brazil. Emerg. Infect. Dis. 11:1458-1460.[Medline]
16
16. Schreckenberger, P. (ed.). 2000. Practical approach to the identification of glucose-nonfermenting gram-negative bacilli. A guide to identification, 2nd ed. University of Illinois College of Medicine, Chicago, IL.
17
17. Schülin, T., and I. Steinmetz. 2001. Chronic melioidosis in a patient with cystic fibrosis. J. Clin. Microbiol. 39:1676-1677.[Abstract/Free Full Text]
18
18. Visca, P., G. Cazzola, A. Petrucca, and C. Braggion. 2001. Travel-associated Burkholderia pseudomallei infection (melioidosis) in a patient with cystic fibrosis: a case report. Clin. Infect. Dis. 32:e15-e16.[CrossRef][Medline]

---

Journal of Clinical Microbiology, December 2007, p. 4077-4080, Vol. 45, No. 12
0095-1137/07/$08.00+0     doi:10.1128/JCM.01386-07
Copyright © 2007, American Society for Microbiology. All Rights Reserved.

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints and Permissions Copyright Information Books from ASM Press MicrobeWorld Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Barth, A. L. Articles by de Andrade Marques, E. Search for Related Content PubMed PubMed Citation Articles by Barth, A. L. Articles by de Andrade Marques, E.