Infective Endocarditis - An uncommon presentation of disseminated melioidosis: a case report

Melioidosis is a potentially fatal bacterial infection involving multiple organ systems and is increasingly being reported in Sri Lanka in recent times. The clinical presentation of the disease varies from localized cutaneous infections to sepsis and death. Involvement of the heart in melioidosis is rare and only a few cases have been described so far in the world literature.Herein we report a case of infective endocarditis in a 53-year-old man with poorly controlled type 2 diabetes mellitus for 5 years duration, who presented with intermittent low-grade fever along with loss of appetite, and malaise for 5 months duration. Examination revealed tachycardia, generalized abdominal tenderness, and coarse crackles on the left lower lobe of the lung. No peripheral stigmata of infective endocarditis or murmur were present. Blood cultures were positive for Burkholderia pseudomallei. 2D echocardiography was performed to exclude infective endocarditis as a cause of prolonged fever which showed a healed vegetation on the mitral valve and contrast-enhanced computerized tomography revealed renal, liver, and lung abscesses with splenic infarctions. A diagnosis of disseminated melioidosis was made. He was successfully treated with three weeks of initial intensive therapy with intravenous meropenem and oral sulfamethoxazole-trimethoprim (TMP-SMX) followed by subsequent three-month eradication therapy with TMP-SMX. Disseminated melioidosis can manifest as infective endocarditis hence a high index of clinical suspicion along with 2D echocardiography and other relevant investigations are crucial for the diagnosis. Initiation of intensive therapy with meropenem in combination with TMP-SMX as an adjunct can be lifesaving.