Case contribution: Dr Radhiana Hassan


  • A 45 years old man
  • Underlying DM on oral medication
  • Presented with productive cough for one week
  • In ED, diagnosed DKA secondary to partially treated pneumonia
  • Dxt= 16.6, HR=141 bpm, BP= 162/100mmHg, Temperature= 39.9°C
Chest radiograph PA erect view shows no significant abnormality

Ultrasound findings:

  • There is hepatosplenomegaly.
  • Hypoechoic lesions are seen within the liver (yellow arrows) and spleen (red arrow) may represent abscess formation.
  • Thickened gallbladder wall with pericholecystic fluid could represent cholecystitis.
  • Slightly thickened urinary bladder wall with floating debris within urinary bladder may represent cystitis.
  • No free fluid is seen.

CT scan findings:

  • Liver is enlarged measuring about 25.2 cm in craniocaudal length.
  • Multiple small peripherally enhancing ill-defined multiloculated lesions with central low attenuation are identified in the liver suggestive of abscesses (yellow arrows).
  • Ill-defined multiloculated non-enhancing hypodense lesion is also seen in the spleen suggestive of another foci of abscess formations (red arrows).
  • The gallbladder is distended with thickened enhancing wall and pericholecystic fluid collection (blue arrow). No layering density within. No gallbladder calculus.
  • Part of the small bowel wall appears slightly thickened with associated minimal surrounding fat stranding (white arrows). These possibly represent extension of inflammation.No bowel wall dilatation or perforation is seen.
  • Pancreas is normal. Bilateral adrenals are normal. Prostate gland is also normal.
  • Consolidation of bibasal lung with pleural effusion, more on the left side (green arrows)

Diagnosis: Meliodosis with multiorgan involvement.


  • Meliodosis is an infectious disease caused by Burkholderia pseudomallei.
  • The presenting symptoms are non-specific ranges from mild to severe illness.
  • Humans are infected with B.pseudomallei by contact with polluted water.
  • The infection is constantly present in Southeast Asia and northern Australia.
  • Those with melioidosis are treated with a long course of antibiotics.
  • Even if the disease is properly treated, approximately 10% of people with melioidosis die from the disease. If the disease is improperly treated, the death rate could reach 40%
  • Diabetes is a major risk factor for melioidosis; over half of melioidosis cases are in people with diabetes.
  • Imaging features depends on organ involvement:
    • Pulmonary: multiple small pulmonary nodules (hematogenous spread) and multilobar infiltrates typically starting in the upper lobes. It can rapidly progress to cavitation or abscess formation.
    • Head and neck: suppurative parotitis is seen and present as an abscess.
    • Abdominal: Liver and spleen abscesses. Less commonly seen in pancreas, kidneys and prostate gland.
    • CNS: cerebral abscess, cerebritis, encephalitis and dural venous sinus thrombosis.

Progress of patient:

  • Initially admitted to ICU due to sepsis
  • Obstructive jaundice due to acalculous cholecystitis
  • Diagnosed meliodosis based on positive serology result.
  • Treated with antibiotic, showed good response and discharged well
  • Repeat CT scan one month later shows small residual abscesses in the liver and spleen.


Author: radhianahassan