Temporomandibular joint septic arthritis: A rare manifestation of melioidosis

Melioidosis is a community-acquired infectious disease that is caused by the Gram-negative bacillus, Burkholderia pseudomallei. It is endemic in Southeast Asia countries, and its clinical spectrum is broad, often mimicking other illnesses, which make diagnosis challenging. The hallmark of its presentation is formation of abscess most commonly in the lungs. The overall mortality rate owing to melioidosis is extremely high especially in the bacteremia form. A 54-year-old woman presented with fever, limited mouth opening, and painful left preauricular swelling for 3 months. Premorbidly, she was well without underlying medical illnesses particularly diabetes or autoimmune disease. Local examination revealed a tender diffuse swelling at the left preauricular region. Her mouth opening was limited to two fingerbreadths. Hematological test showed raised total white cells, erythrocyte sedimentation rate and C-reactive protein. Computed tomography and MRI showed presence of significant left masseteric collection with erosion of left temporomandibular condyle. Other incidental findings from the imaging were multiple liver abscesses and right lower lung abscess. Her indirect immunofluorescence enzyme-linked immunosorbent assay and enzyme-linked immunosorbent assay diagnostic test was positive with significant titre ratio of 1 : 320, which established the diagnosis of melioidosis. Full recovery was attained following surgical drainage of the abscess, together with antibiotics for 6 months (intravenous ceftazidime for a month, followed by oral augmentin for 5 months). Melioidosis involving the TMJ joint is a rare entity. This is the second reported case of melioidosis affecting TMJ joint worldwide, from extensive literature search. This case highlights the importance of suspecting melioidosis in individual presenting with abscess at uncommon and atypical site. Enzyme-linked immunosorbent assay is a rapid test as compared to the gold standard blood culture, and it helps in reaching the diagnosis early with its advantages of high sensitivity and specificity.