Massive calvarial melioidosis abscess following minor trauma in rural areas of Thailand.

Background: Melioidosis is uncommon but endemic in Southeast Asia and parts of Northern Australia. Cerebral melioidosis is rare but can be spread through several routes, such as hematogenous spreading or the direct inoculation of organisms from wound contamination with soil. It can cause devastating sequelae if the treatment is delayed. However, with early and adequate treatment, patients can recover and have a good quality of life.

Case description: A 62-year-old diabetic male presented with epilepsy 2 months after a head injury. A computed tomography scan revealed an abscess extending from the subgaleal layer to the subdural with osteomyelitis. A craniotomy was performed to remove the abscess. Melioidosis was identified from pus culture. Intravenous meropenem with Bactrim was started, followed by oral doxycycline and bactrim. The patient recovered with no seizure episodes. This patient showed a rare but straightforward infection from direct inoculation in a wound contaminated with soil. Incubation time could be up to 2 months. The infection originates from previously lacerated scalp tissue and invades the skull, causing osteomyelitis and epidural abscess. Prompt treatment brings a good outcome. In patients with risk factors and a suspicious history, broad-spectrum antibiotics should be initiated after removal of the abscess.

Conclusion: Melioidosis is still endemic in Thailand. Doctors should be aware of this organism in patients with high-risk factors or travelers who have just returned from an endemic area. Patients should be treated early with an adequate dose and duration of anti-melioidosis.