Brought with the wind: A case of melioidosis acquired in the United States presenting with multiple pulmonary nodules.

Abstract

Burkholderia pseudomallei, the causative agent of melioidosis, is a gram-negative bacterium historically endemic to Southeast Asia and Northern Australia. However, recent environmental detection along the Gulf Coast and an increasing number of reported cases in non-travelers have raised questions regarding potential endemicity and environmental establishment in the Southern United States. We report a case of putatively locally acquired pulmonary melioidosis in a Florida resident with no recent international travel history, illustrating the diagnostic and therapeutic challenges posed by this rare pathogen. The patient presented with fever, pleuritic chest pain, and hypoxia following a period of severe weather. Computed tomography (CT) of the chest revealed multiple solid pulmonary nodules with ground-glass opacities and mediastinal lymphadenopathy. Given his underlying stage 3b chronic kidney disease (CKD), the patient was treated with an intensive course of intravenous ceftazidime followed by oral doxycycline monotherapy, achieving full clinical recovery. Follow-up imaging at 3 months demonstrated complete resolution of the pulmonary nodules. This case emphasizes the importance of considering melioidosis in the differential diagnosis for non-resolving community-acquired pneumonia or significant pulmonary nodules in the Southern United States, even in the absence of international travel. Risk factors such as diabetes mellitus and severe weather events are key clinical clues. While trimethoprim-sulfamethoxazole remains the preferred eradication therapy, doxycycline may serve as a potential alternative for patients with renal impairment when first-line therapy is contraindicated.