melioidosis is predominantly a tropical disease and most cases are reported during the rainy season in endemic area . it is characterized by abscess - formation in the lung , liver , spleen , skeletal muscle and prostate with the lung being the most commonly involved organ . the clinical features are variable from rapidly progressing septicemia to chronic debilitating abscess - forming disease . understanding about melioidosis is important in tuberculosis endemic areas , because its progression and roentgenographic findings are so similar to tuberculosis that it is not rare for melioidosis to be misdiagnosed as tuberculosis . the patient was a 50-yr - old man who was diagnosed with melioidosis on bronchoscopic washing culture and whose symptoms improved after treatment with high dose ceftazidime . a 50-yr - old man visited our hospital because of intermittent fever associated with cough , sputum , generalized myalgia and general weakness for about four weeks . he had lived in indonesia for twenty years for business , and visited a local hospital in indonesia and was treated for typhoid fever without improvement of symptoms . initial chest radiograph and computed tomography ( ct ) images showed multiple satellite nodules in the left lower and upper lobes , and judging from that roentgenographic examination , tuberculosis was the most probable diagnosis ( fig . 1 ) . bronchoscopy showed no endobronchial lesion and washing cytology and culture were also negative . three months later we rechecked chest radiograph and ct findings , and found new infiltration in the left lower lobe and improvement of lesions in the left upper and lower lobes ( fig . laboratory findings included white blood cell count of 5,240/l and hemoglobin value of 11.6 g / dl . iga was 227 mg / dl ( normal range : 90 - 400 mg / dl ) and anti - neutrophilic cytoplasmic antibodies with cytoplasmic staining pattern ( canca ) was negative . however , secretion was seen in left lower lobe , so washing cytology and culture was done . cytology was negative but a species of bacteria grew on blood agar media ( fig . 3 ) . it was gram - negative , non - spore forming and showed as a safety pin shaped organism on microscopic examination ( fig . api20ne strip and vitek gni card ( biomerieux , inc . , hazelwood , u.s.a . ) , the organism was identified as burkholderia pseudomallei ( 1 ) . on dna sequencing of 16s ribosomal rna , it was compatible with b. pseudomallei with 100% homology and formed a characteristic rugose colony on blood agar . we prescribed ceftazidime 2 g intravenously every 8 hr and he did not complain of intermittent fever any more . after one week of intravenous ceftazidime , he was discharged with oral amoxicillin - clavulanate ( 750 mg every 8 hr ) . one month later the cough and sputum were almost disappeared but his general weakness persisted although it was also improving . four months later we rechecked chest ct to show an improvement of infiltration in left lower lobe . he said his condition was as good as his previous state before suffering from melioidosis . one month later , we stopped administrating oral antibiotics to him , which resulted in him taking amoxicillin - clavulanate for total five months . the endemic area includes southeast asia , north australia , madagascar , and guam ( 2 ) . in northeast thailand , melioidosis accounts for 20% of all community - acquired septicemias , and causes death in 40% of treated patients . melioidosis was first described by whitmore in 1911 and more than 100 cases had been reported by 1917 ( 3 ) . since then , with sporadic cases being reported during and after world war ii and many soldiers fighting in vietnam suffering from this disease , western countries began to take an interest in melioidosis . b. pseudomallei is a motile aerobic , non - spore - forming and gram - negative bacillus . the colonies develop a rugose appearance , and take up crystal violet dye from the medium . although it is gram - negative bacterium , it is usually resistant to aminoglycoside , 1st & 2nd cephalosporin , macrolide , rifamycin and colistin , but is susceptible to ampicillin / sulbactam , chloramphenicol , tetracycline , bactrim , 3rd cepha and carbapenem ( 4 ) . b. pseudomallei is a soil saprophyte and can be recovered readily from water and wet soils in rice paddy fields . for example , in thailand the organism can be cultured readily from more than 50% of rice paddies ( 5 ) . it presents as a febrile illness , ranging from an acute fulminant sepsis to a chronic debilitating localized infection . the lung is the most commonly affected organ , either presenting with cough and fever resulting from a primary lung abscess or pneumonia . seeding and abscess formation can arise in any organ , and the liver , spleen , skeletal muscle and prostate are common sites . localized pulmonary melioidosis often can not be differentiated from tuberculosis on clinical and chest radiography findings . first , some melioidosis cases have rapid clinical and roentgenographic progression within a few days . second , melioidosis usually responds to treatment well and has apparent roentgenographic improvement within 1 - 2 weeks . third , parapneumonic effusion develops in 5 - 15% of cases , but the amount is not large and associated pulmonary infiltration is always present . in contrast , tuberculosis pleurisy in which a large amount of pleural fluid is present without underlying pulmonary infiltration is common . diagnosis of melioidosis is made by isolation of b. pseudomallei from any site ; for example blood , sputum , abscess fluid and throat swab . since splenic abscess is much less common in other diseases , its presence is more likely to suggest melioidosis . the antibiotic of choice is ceftazidime ( 40 mg / kg intravenous injection every 8 hr ) , while other 3rd generation cephalosporin is less effective ( 9 ) . four - drug combination is usually recommended as oral antibiotics , and those are chloramphenicol ( 40 mg / kg per day in four divided doses ) , doxycycline ( 4 mg / kg per day in two divided doses ) , trimethoprim - sulfamethoxazole ( 10 mg and 50 mg / kg per day , respectively , in two divided doses ) . high dose ceftazidime followed by long term oral antibiotics is considered to be most effective treatment . the distribution and frequency of melioidosis is probably greatly underestimated ( 10 ) . in tuberculosis endemic areas , it is important to understand melioidosis and differentiate this disease from tuberculosis because the treatment of the two diseases is completely different .
melioidosis is an infection of the gram - negative bacterium burkholderia pseudomallei . 
 while it is known as an important cause of sepsis or chronic abscess - forming disease in southeast asia and northern australia , no case has yet been reported in korea . 
 a 50-yr - old man visited our hospital for intermittent fever associated with dry cough and sputum . 
 roentgenographic examination showed migrating pulmonary infiltration . 
 symptoms and chest radiograph and computed tomography ( ct ) image findings did not improve despite use of fluoroquinolone antibiotics . 
 gram - negative bacteria were isolated on bronchoscopic washing culture and were identified as b. pseudomallei on dna sequencing of 16s ribosomal rna with 100% homology . 
 treatment for melioidosis was commenced with high dose ceftazidime , and the patient 's fever , cough , and sputum were improved and the lesion on chest radiograph and ct almost disappeared .