CBRNE - Glanders and Melioidosis Clinical Presentation

Updated: Jan 17, 2019
  • Author: Paul P Rega, MD, FACEP; Chief Editor: Duane C Caneva, MD, MSc  more...
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Presentation

History

There is nothing specific about the presentation of these diseases and a strong clinical suspicion is required to assist in making a diagnosis in endemic regions. This is particularly true for patients with predisposing comorbidities, such as diabetes mellitus, chronic renal failure, alcoholism or malignancy; those who are immunosuppressed as the result of either diseases or drug treatment; and those living in or with a history of travel to endemic areas.  [19]

Glanders

Glanders is primarily zoonotic. It is transmitted to humans through direct skin or mucous membrane contact with infected animal tissues. It may also be inhaled via infected aerosols or dust contaminated by infected animals. No cases of human-to-human transmission have been reported in the United States. [16]

General symptoms of glanders include fever with chills and sweating, muscle aches, chest pain, muscle tightness, headache, nasal discharge and light sensitivity. If there is a cut or scratch in the skin, a localized infection with ulceration may develop within 1 to 5 days at the site where the bacteria entered the body. Swollen lymph nodes may also be present.

Infections involving the mucous membranes in the eyes, nose, and respiratory tract will cause increased mucus production from the affected sites. Dissemination to other locations in the body may occur 1-4 weeks after infection. Glanders often manifests as pulmonary infection with pneumonia, pulmonary abscesses, and pleural effusion.  [2]

The chronic form of glanders involves multiple abscesses within the muscles and skin of the arms and legs or in the lungs, spleen, or liver.

Melioidosis

Melioidosis is transmitted to humans through direct skin contact with contaminated soil or water. Ingestion of contaminated water and inhalation of dust contaminated with the organism are other mechanisms of transmission. Cases of human-to-human transmission are rare but have been documented. The time between an exposure to the bacteria and the emergence of symptoms is not clearly defined, but may range from one day to many years; generally symptoms appear two to four weeks after exposure. [18]

There are several types of melioidosis infection, each with their own set of symptoms. Melioidosis can be categorized as an acute or localized infection, acute pulmonary infection, acute bloodstream infection, or disseminated infection. Sub-clinical infections are also possible. The localized form generally presents as an ulcer, nodule, or skin abscess that may result from inoculation through a break in the skin and cause fever and general muscle aches. The infection may remain localized, or may progress rapidly through the bloodstream.

The onset of pulmonary melioidosis is marked by a high fever, headache, anorexia, general muscle soreness and chest pain. The hallmark of pulmonary melioidosis.is a cough with normal sputum.

Disseminated melioidosis presents with abscess formation in various organs of the body, and may be associated with sepsis. Organs involved  include the liver, lung, spleen, and prostate; involvement of joints, bones, viscera, lymph nodes, skin, or brain may also occur. Disseminated infection is seen in acute or chronic melioidosis. Signs and symptoms, in addition to fever, include weight loss, stomach or chest pain, muscle or joint pain, and headache or seizure.

Patients with diabetes and renal insufficiency are more likely to develop a bloodstream infection leading to septic shock. The symptoms include fever, headache, respiratory distress, abdominal discomfort, joint pain, muscle tenderness, and disorientation. This is typically an infection with rapid onset, and abscesses may be found throughout the body, most notably in the liver, spleen, or prostate. [4, 5]

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Physical

Physical findings may include fever, cervical adenopathy, hepatomegaly, or splenomegaly, and skin lesions including the following:.

  • Severe urticaria has been reported during primary melioidosis

  • During septicemia, flushing, cyanosis, and a disseminated pustular eruption can be seen. Pustules often are associated with regional lymphadenitis, cellulitis, or lymphangitis

  • Rarely, ecthyma gangrenosum–like lesions and cutaneous abscesses (that sometimes ulcerate) may develop

Specifically, in melioidosis septicemia, high fevers and rigor are present. These findings may be accompanied by confusion, dyspnea, abdominal pain, muscle tenderness, pharyngitis, diarrhea, and jaundice. While the typical foci in these severe cases begin from the skin or the lungs, metastasis (liver, spleen, kidney, brainstem, parotid gland) will occur, leading to acidosis, shock, and death within 48 hours of presentation. [4, 5]

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Causes

Glanders is primarily zoonotic. It is rare in humans, and no epidemics have been reported. Human cases of glanders have occurred primarily in occupational settings and include laboratorians, veterinarians, and animal caretakers.

Human cases of melioidosis have been transmitted via sexual contact and intravenous drug use. The disease has been observed in immigrants, military personnel, and travelers.  Diabetes is considered as an important risk factor. [4]

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Physical Examination

A recent review of melioidosis in Malaysia revealed the major findings on clinical exam:

Pneumonia and soft tissue abscesses were the most prominent findings.   [4]  

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Complications

For melioidosis:  Septic shock, abscesses of the liver, spleen, and prostate, and death

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