Melioidosis is characterised by fever, pneumonia, and abscesses, although there is a spectrum of severity from mild, localised infections to disseminated infection causing rapidly fatal sepsis. Glanders is uncommon in humans.
Diagnosis of melioidosis is a challenge as it mimics many other conditions, especially tuberculosis. Diagnosis of both conditions requires a high index of suspicion from the clinical presentation, and must be confirmed by culture of B pseudomallei or B mallei.
Initial intensive intravenous antibiotic treatment is the mainstay of therapy in most patients and may be required for weeks, depending on clinical circumstances. This is followed by a minimum of 3 months of oral eradication therapy to reduce the risk of relapse.
Mortality associated with melioidosis is still up to 50% in many endemic regions, but as low as 10% if there is access to timely diagnosis, appropriate antibiotics, and state-of-the-art intensive supportive care.
Both conditions are caused by bacteria of the Burkholderia genus and present with broadly similar symptoms, characterised by fever, pneumonia, and abscesses, although there is a spectrum of severity from mild, localised infections to disseminated infection causing rapidly fatal sepsis.
Melioidosis, also called Whitmore's disease, Nightcliff gardener's disease, pseudoglanders, or the 'Vietnam time bomb', is caused by the bacterium Burkholderia pseudomallei. The bacterium is a saprophyte found in soil and water throughout the tropics, especially Southeast Asia and northern Australia. Humans and other animals become infected by exposure to the organism in the environment.
Glanders is caused by the bacterium Burkholderia mallei. This is a close relative of B pseudomallei that has become adapted to life as an obligate pathogen of equines (i.e., horses, donkeys, and mules). It can sometimes be transmitted to humans through contact with tissues or body fluids of infected animals. In the past, human glanders occurred sporadically in those involved in working with horses (e.g., grooms and veterinarians) but since equine glanders was controlled and society became less dependent on horses, human glanders has almost completely disappeared. Only a single, laboratory-acquired, case has been reported in the literature in the last 60 years.
History and exam
Key diagnostic factors
- presence of risk factors
- septic shock
- regional lymphadenitis/parotitis
- non-healing skin sore/ulcer or abscess
- bacteraemia without evident clinical focus
- lower motor neuron cranial nerve palsies (especially cranial nerves VII and VIII)
- flaccid paralysis
Other diagnostic factors
- shortness of breath
- abdominal pain/diarrhoea
- urinary retention
- other signs of organ abscess
- altered conscious state
- mycotic pseudo-aneurysms
- travel to endemic area
- occupational/recreational environmental exposure
- hazardous alcohol use
- chronic renal or liver disease
- malignancy and immunosuppressive therapy
- cystic fibrosis and other chronic lung disease
1st investigations to order
- blood culture
- sputum culture
- urine culture
- culture of pus/swab from skin lesion, abscess, lymphadenitis, drained internal abscess (e.g., liver abscess)
- chest x-ray
- computer tomography (CT) abdomen and pelvis ± CT chest
- abdominal/pelvis ultrasound
Investigations to consider
- throat swab in/on Ashdown's selective broth/agar
- rectal swab in/on Ashdown's selective broth/agar
- cerebrospinal fluid (CSF) culture
- CSF microscopy, protein and glucose
- polymerase chain reaction (PCR)
- rapid antigen detection test
non-localised disease or patient systemically unwell
intensive intravenous antibiotic therapy completed; localised disease responsive to oral eradiation therapy
Bart J. Currie, MBBS, FRACP, FAFPHM, DTM+H
Professor in Medicine
Northern Territory Medical Program
Royal Darwin Hospital
Head of Tropical and Emerging Infectious Diseases
Menzies School of Health Research
Charles Darwin University
BJC is the author of several references cited in this topic.
David A.B. Dance, MB, ChB, MSc, FRCPath
Senior Clinical Research Fellow/Consultant Microbiologist
Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit
Centre for Tropical Medicine and Global Health
University of Oxford
Faculty of Infectious and Tropical Diseases
London School of Hygiene and Tropical Medicine
DABD is the author of several references cited in this topic. DABD has acted as a consultant to Soligenix Inc. and has worked with InBios on the evaluation of diagnostic tests for melioidosis.
Robert Norton, MBBCh (Hons), MRCP (UK), FRCPA, MD
Director of Microbiology
RN declares that he has no competing interests.
Ploenchan Chetchotisakd, MD
Professor of Medicine
Faculty of Medicine
Khon Kaen University
PC declares that he has no competing interests.
- Glanders: guidance for healthcare providers
- Glanders: guidance for healthcare providers
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer