99mTc-MDP whole body bone scan in a case of acute disseminated melioidosis

Melioidosis is a potentially fatal infectious disease occurring predominantly in the tropics, caused by a Gram-negative, motile, rod shaped obligatory aerobic non-spore forming bacillus, Burkholderia pseudomallei. It can produce localised or disseminated disease largely affecting immunocompromised patients. It is a challenge to identify melioidosis early as this disease can manipulate host's cellular immune response to escape detection. Although musculoskeletal involvement in melioidosis is said to be the predominant manifestation, reports have shown widespread involvement in the form of abscesses in lung, liver and spleen etc. It predominantly occurs in patients with diabetes mellitus or those suffering from chronic alcohol abuse, cirrhosis, smoking, chronic lung disease or patients on longstanding corticosteroid use. We present a 43-year-old diabetic male with fever and headache of 5 months duration, abdominal and left sided hip pain with difficulty in walking for 3 weeks. (99)mTc-MDP three phase bone scan revealed increased tracer uptake in left femur leading to a diagnosis of focal osteomyelitis. In view of dull aching, intermittent abdominal pain, further investigation was carried out. Contrast enhanced CT abdomen showed hepatosplenomegaly with rim enhancing tiny lesions scattered in liver and spleen suggesting possibility of micro abscesses. Serial blood cultures grew Gram-negative bacilli, which was later identified as B.pseudomallei. Patient was subsequently started on meropenem, doxycycline and cotrimoxazole. Bone scan was the first investigation to identify the pathology and mooted further investigation to identify visceral involvement guiding appropriate management. He was followed up for a period of 6 months and had an uneventful recovery.