Septicaemic pulmonary melioidosis with cutaneous pustules.

A 51 year old diabetic man who worked as a ranger in a wildlife reserve in Jelebu, N egeri Sembilan, was admitted because of fever and non-productive cough which had started 8 days earlier. He was initially treated at a district hospital, followed by an admission to the general hospital of another state. When he became progressively breathless and developed widespread skin pustules he was transferred to a private medical centre, where a chest radiograph (Fig 1) was taken and revealed extensive, bilateral nodular opacities which were confluent in certain areas without evidence of cavitation or pleural effusion. He was treated as staphylococcal pneumonia with intravenous cloxacillin and netilmicin. He was transferred to this hospital when his condition continued to worsen. On admission, he was very ill with a temperature of 40oC. Multiple cutaneous pustules were present on his face, trunk and limbs (Fig 2). He was tachypnoeic and crackles were heard over both lungs. Hypoxaemia, with a Pa02 of76 mm Hg, was present when he was receiving oxygen at 10 lImin through a face mask. Gram staining of pus from one of the cutaneous pustules revealed small gram-negative bacilli. At this point in time, Pseudomonas pseudomallei pneumonia with septicaemia was considered a likely diagnosis and intravenous ceftazidime at 2 gm tds and intravenous trimethoprim-sulphamethoxazole (cotrimoxazole) at 1920 mg bd was promptly commenced after 2 blood specimens and pus from one of the cutaneous pustules had been taken for cultute. Culture of pus and the blood cultutes both grew Ps pseudo mallei that was sensitive to ceftazidime, chloramphenicol and cotrimoxazole. His clinical condition improved dramatically, and by the third day he was afebrile.