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CC BY-NC-ND 4.0 · Journal of Gastrointestinal Infections 2025; 15(01/02): 38-41
DOI: 10.1055/s-0045-1811251
Case Report

A Case Report: Liver and Splenic Abscess Caused by Burkholderia pseudomallei

Authors

  • K. T. Sangeetha

    1   Department of Microbiology, Manipal Hospital Whitefield, Bengaluru, Karnataka, India

  • Balaji Laxminarayan Shetty B.

    2   Department of Gastroenterology, Manipal Hospital Whitefield, Bengaluru, Karnataka, India

  • Manogya Gupta

    1   Department of Microbiology, Manipal Hospital Whitefield, Bengaluru, Karnataka, India

Funding None.
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Abstract

Melioidosis is an emerging infectious disease in India which presents with febrile illness ranging from septicemia to localized abscess formation. We present a case of a 61-year-old male who presented with fever of almost 2 months' duration, persistent pneumonia, and liver and splenic abscesses. Aspiration of hepatic fluid collection and subsequent culture yielded Gram-negative bacilli, which was identified as Burkholderia pseudomallei. He was treated successfully with surgical drainage of abscess and prolonged course of intravenous and oral antibiotics. So, in cases of pyogenic liver abscess not responding to conventional antibiotics, B. pseudomallei should always be thought as a possible cause, which can be identified by its characteristic appearance on culture and microscopy and accurately identified by automated identification systems.


Keywords

melioidosis - liver and splenic abscess - Burkholderia pseudomallei

Introduction

Burkholderia pseudomallei, a Gram-negative bacterium, is the causative agent of the systemic infection known as melioidosis. In South East Asia, particularly in Thailand, it is a frequent cause of septicemia, accounting for 20% of all cases of community-acquired septicemia.[1] Melioidosis is endemic in northern Australia, where it is considered a major public health concern, as well as in many parts of Southeast Asia, including Thailand, Vietnam, and Malaysia. In the Indian subcontinent, it has become increasingly recognized, particularly in regions like southern India. However, it remains underdiagnosed and relatively less understood compared to other endemic areas.[2]

B. pseudomallei is found in soil and water and can infect humans through inoculation, inhalation, or ingestion.[3] In endemic areas individuals exposed to soil and surface waters are more prone to infections due to B. pseudomallei, but active disease primarily occurs in patients with underlying predisposing conditions like diabetes mellitus, renal disease, alcoholism, liver cirrhosis, chronic lung disease, malnutrition, and use of immunosuppressive agents. Melioidosis presents as a febrile illness ranging from septicemia to localized abscess formation especially in the lungs, liver, spleen, skeletal muscle, and prostate.[4]

Melioidosis cases have been reported from the southern coastal region of India, but only few cases of liver and splenic abscess have been reported from India. Melioidosis should always be considered in cases with liver with splenic abscess that are not responsive to standard antibiotics. Given the high mortality rate, prompt identification and thorough treatment are essential in this situation.[5]


Case Report

A 61-year-old male came with fever since 2 months, cough with expectoration, generalized weakness, and weight loss since 1 month. He was a known diabetic (type 2) on oral hypoglycemic agents. Also, he had coronavirus disease 2019 infection 2 months prior to these symptoms. He had bone and brain abscesses and pneumonia with pleural effusion 10 years back. He had no history of tuberculosis or travel.

On admission, he was started on empirical antibiotic treatment (piperacillin/tazobactam and amikacin) and other supportive measures. His total leukocyte count was 9000 cu.mm with 67.2% neutrophils and 21.9% lymphocytes on admission. Renal and liver function tests were within normal limits except for raised gamma-glutamyl transferase ([Table 1]).

Table 1

Blood investigations

Blood investigations:

Total WBC count

9000/cu.mm

Differential count:

Neutrophils

67.2%

Lymphocytes

21.9%

Platelet count

329000/ cu.mm

CRP

173.10 mg/L

SGOT

25 U/L

SGPT

40 U/L

Gamma-glutamyl transferase

95 U/L

Plasma glucose random

281 mg/dL

Echinococcus (hydatid cyst) IgG

Negative

Amoebiasis antibodies - IgG

Negative

Abbreviations: CRP, C- reactive protein; IgG, Immunoglobulin G; SGOT, Serum glutamic oxaloacetic transaminase test; SGPT, Serum glutamate pyruvate transaminase test; WBC, White blood cell.


Computed tomography (CT) abdomen showed irregular multiloculated hypodense lesion in segment IVa of liver measuring 5 × 4 × 3.9 cm. It showed enhancing septae, suggestive of abscess. The spleen was enlarged measuring 16 cm. It showed multiple hypodense lesions suggestive of abscesses, largest measuring 6 × 2.6 cm, which showed rupture into the subcapsular space ([Fig. 1]).

Zoom
Fig. 1 Computed tomography (CT) abdomen showing one loculated hypodense lesion with irregular inner margin noted in the right lobe of the liver.

CT thorax showed mild broncheictatic changes. No pleural effusion.

Ultrasound-guided percutaneous aspiration of the liver abscess was done which revealed thick pus. The pus aspirate was inoculated into blood agar and MacConkey agar. After 48 to 72 hours of aerobic incubation at 37°C, large, dry, wrinkled colonies were grown on blood agar and MacConkey agar ([Fig. 2]). Gram's stain from these colonies showed Gram-negative rods with typical bipolar “safety-pin” appearance indicating Burkholderia species ([Fig. 3]). The colonies also showed positive oxidase and catalase reaction. The isolated colonies were processed in VITEK 2 automated culture system and the organism was identified as B. pseudomallei. The organism was susceptible to carbapenems and cotrimoxazole. The patient was started on meropenem and cotrimoxazole, which was continued for 2 weeks and later oral cotrimoxazole was prescribed for the eradication phase. He was also shifted to intravenous insulin from oral hypoglycemic agents due to steroid-induced hyperglycemia. His symptoms gradually resolved and the follow-up CT abdomen after 6 months showed complete resolution of liver and splenic abscesses.

Zoom
Fig. 2 Colony morphology in blood agar (A) and MacConkey agar (B) and MacConkey agar showing large, dry wrinkled colonies of Burkholderia pseudomallei.
Zoom
Fig. 3 Gram staining showing Gram-negative bacilli with typical bipolar safety pin appearance indicating Burkholderia pseudomallei.

Discussion

Melioidosis, caused by the bacterium B. pseudomallei, presents a diverse range of clinical manifestations, with hepatic involvement being a particularly challenging and intriguing aspect. This discussion explores the nuances of melioidosis in the context of hepatic abscesses, shedding light on its clinical presentation, diagnostic challenges, and treatment strategies. Various studies from India highlight the diversity of clinical presentation seen with melioidosis. The most common clinical manifestations include fever, pneumonia, multiorgan abscesses, septicemia, and occasionally neurological and joint involvement.[6] [7] [8]

The lung is the most commonly affected organ. Abscesses in the liver and spleen could be limited to disseminated cases. Liver abscess due to melioidosis can mimic pyogenic liver abscess or cryptic tuberculosis. Hence, melioidosis was known as “The remarkable imitator” and the great masquerader.[5] [9] [10] Splenic involvement is very rare in cases of liver abscess due to Entamoeba histolytica and pyogenic bacteria, which should alert one to the possibility of melioidosis. In Thailand, 95% of splenic abscesses are due to B. pseudomallei.[4] [11] A study conducted by Raj et al also accounts for a greater frequency of splenic and liver abscess compared to other organ sites in melioidosis cases.[12]

In our case, the predisposing factor for melioidosis was diabetes mellitus. Diabetes mellitus was the most common predisposing factor in various other Indian studies.[6] [7] Various other risk factors like disease occurrence in rainy season, male sex, and age > 45 years also correlates with other studies.[13] [14] Our case also presented in the month of July, during the rainy season.

In each organ, several abscesses are more frequent than a single abscess. Study by Iyer et al also revealed multiple abscesses in liver and spleen similar to our case.[15] CT scan findings usually include liver abscesses with a “honeycomb” pattern of multiseptate, multiloculated lesions. These “honeycomb” appearance on a CT scan are described as being highly predictive of melioidosis.[16]

Definitive diagnosis can be made by culture of B. pseudomallei from clinical specimens along with accurate identification of organism using automated systems. Few conventional identification methods like the presence of Gram-negative, oxidase positive bacilli with bipolar staining pattern or safety pin appearance, and rough wrinkled pink colonies with metallic sheen after prolonged incubation on MacConkey's agar and with unusual susceptibility pattern (susceptible to amoxicillin-clavulanic acid and resistant to aminoglycosides and colistin) can hint toward B. pseudomallei.[6] [13]

Culture-based diagnostic tests remain the gold standard; however, they are time consuming, prone to misidentification, and may not always yield positive results due to the inappropriate use of broad-spectrum antibiotics. Serological tests such as hemagglutination lack sensitivity and specificity owing to high seropositivity rates in endemic areas. polymerase chain reaction-based assays are excellent alternatives for the rapid diagnosis of melioidosis.[8]

The treatment of melioidosis includes an intravenous intensive phase and an eradication phase. Ceftazidime or carbapenems are used in the intensive phase (10–14 days) and trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline or amoxicillin-clavulanic acid alone or in combination are employed for the eradication phase lasting for 3 to 6 months.[17] In our case, B. pseudomallei was resistant to ceftazidime, hence the patient was started on intravenous meropenem and trimethoprim-sulfamethoxazole initially for 2 weeks during the intensive phase. A randomized trial indicated that combining ceftazidime and cotrimoxazole together reduced mortality.[18] The eradication phase consisted of treatment with oral trimethoprim-sulfamethoxazole for 6 months.[19]


Conclusion

This case report highlights the diagnostic challenges posed by cases of prolonged fever with diverse clinical manifestations and overlapping symptoms, which are unresponsive to traditional antibiotics and antitubercular agents. Better awareness among clinicians and microbiologists can allow in early diagnosis and prompt management, which can significantly reduce the morbidity and mortality associated with this disease. In certain situations it may be prudent to consider B. pseudomallei as a cause of abscess involving multiple organ systems.



Conflict of Interest

None declared.

Acknowledgments

None.

Ethical Statement

None.


Authors' Contributions

All authors contributed equally to the article.


Data Availability Statement

There is no data associated with this work.



Address for correspondence

K. T. Sangeetha, MD
Department of Medical Microbiology, Manipal Hospitals
Whitefield, Bangalore, Karnataka
India   

Publication History

Received: 27 February 2025

Accepted: 27 July 2025

Article published online:
06 October 2025

© 2025. Gastrointestinal Infection Society of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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Zoom
Fig. 1 Computed tomography (CT) abdomen showing one loculated hypodense lesion with irregular inner margin noted in the right lobe of the liver.
Zoom
Fig. 2 Colony morphology in blood agar (A) and MacConkey agar (B) and MacConkey agar showing large, dry wrinkled colonies of Burkholderia pseudomallei.
Zoom
Fig. 3 Gram staining showing Gram-negative bacilli with typical bipolar safety pin appearance indicating Burkholderia pseudomallei.