melioidosisj

8/6/2019 Melioidosisj

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W A R A Y U W A D E E A M O R N P I N Y O

A P R I L ’ 1 8 2 0 1 1

Melioidosis



Scope

® Introduction of

melioidosis

® Clinical manifestations

® Diagnosis

® Treatment

® Relapsing



Background

� 1911 Alfred Whitmore, Mianma

� Pseudoglanders, Vietnamese time bomb,

Whitmore’s disease, Rangoon begger’s disease

� 1932 Stantonà Melioidosis¡ Melis (distemper of asses)

¡ Eidos (resemblance)



Epidermiology



Bacteriology

n Burkholderia pseudomellei n Gram negative bacilli, bipolar staining

n Safety pin appearancen Intracellular bacteria

n Saprophytic bacteria, aerobic, motile, non-

spore forming



Genus Burkholderia



Animal and melioidosis

� อู ฐ ม้า แกะ วัว แพะ สุกร จิงโจ้ หมี โคอะล่า

อัลปาคัส กวาง แมว สุนัข และ สัตว์ทะเล

� สัตว์ที ดื อต่อการติดเชื อ melioidosis ได้แก่ วัว ควาย จระเข้ นก



Transmissions

n Inhalation

n Ingestion

n Cutaneous contaminationn Nosocomial infection



Factors associated

1) Environmental factors

2) Bacterial virulence factors

3) Host immune response



Environment factors

� aerosol , cutaneous contact

Palasatien S, Lertsirivorakul R, Royros P, Wongratanacheewin S, Sermswan RW. Soil physicochemical propertiesrelated to the presence of Burkholderia pseudomallei. Trans R Soc Trop Med Hyg 2008 Dec;102 Suppl 1:S5-9



Factors associated






Bacterial virulence factors

1) มหีลักฐานนา่เชื อถือ (strong putative candidates)¡ 1.1 Quorum sensing

¡ 1.2 Type III secretion system (TTSS)

¡ 1.3 Capsular polysaccharide

2) พอมหีลักฐานบ้าง (other putative candidates)¡ 2.1 Lipopolysaccharide (LPS)

¡ 2.2 Flagella

¡ 2.3 Type IV pili-mediated adherence

¡ 2.4 A siderophore for iron acquisition¡ 2.5 Secreted proteins เช่น haemolysin, lipases และ proteases

3) Downregulation of virulence



Quorum sensing

� ใน Burkholderia pseudomallei genome :

� N -acyl-homoserine lactones (AHLs)¡ 3 LuxI & 5 LuxR quorum sensing homologuesàincrease

LD50

¡ BpeAB-OprB : multidrug efflux pumpà biofilm

“Resistance to Aminoglycoside,Macrolide”



Type III secretion system (TTSS)



Capsular polysaccharide

� extracellular capsular polysaccharide (type I O-polysaccharide)

� -3)-2-O-acetyl-6-deoxy-beta-d-

mannoheptopyranose-(1-� โดยเชื อว่าอาจเกี ยวกับการยับยั งการจับกันของ

complement receptor-1(CR1) บน phagocytic cells กับ

C3b ท ีอยู ่บนผิวของแบคทีเรีย



Lipopolysaccharide (LPS)� Type II O-antigenic polysaccharide� B.pseudomallei (ก่อโรค) & B. thailandensis( ไมก่่อ โรค)

Flagella : non significant

Type IV pili-mediated adherence :deletion ของ pilA จะทาํให้เชื อ B.pseudomallei จับกับ human epithelial cells ได้น้อยลง ทาํให้ปจจัยก่อความรุนแรงลดลง

� Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev 2005 Apr;18(2):383-416� White NJ. Melioidosis. Lancet 2003 May 17;361(9370):1715-22

� Wiersinga WJ, van der Poll T, White NJ, Day NP, Peacock SJ. Melioidosis: insights into the pathogenicity of Burkholderia pseudomallei. Nat Rev Microbiol 2006 Apr;4(4):272-82



B.thailandensis B.Pseudomallei & mallei� มี arabinose-

assimilation operon� Ara +

� Low virulent

� ไม่มี arabinose-

assimilation operon� Ara –

� High virulent

Downregulation of virulence



Factors associated




v Innate immune response

v Adaptive immune response

v Intracellular survival of Burkholderia pseudomallei

v Interactions with human epithelial cells in vitro



Innate immune response



Adaptive immune response

� Invasive dzàHigh IgG, IgA & IgM

� Septicemic formàHLA class II ¡ พบ DRB1*1602 allele แต่ ไม่พบ DQA1*03 allele29

� Asymptomatic seropositiveà CMIR

Dharakul T, Vejbaesya S, Chaowagul W, Luangtrakool P, Stephens HA, Songsivilai S.

HLA-DR and –DQ associations with melioidosis. Hum Immunol 1998 Sep;59(9):580-6

Wiersinga WJ, van der Poll T, White NJ, Day NP, Peacock SJ. Melioidosis: insights

into the pathogenicity of B.pseudomallei. Nat Rev Microbiol 2006 Apr;4(4):272-82



Intracellular survival of B. pseudomallei



6 Mechanisms :

� 1) ดื อต่อ human defensins

� 2) หลบอยู ่ ใน phagolysosomes

� 3) ไม่กระตุ ้น iNOS

� 4) lysis endosome mb อย่างรวดเร็วในเวลา 15

นาที � 5) Cell-to-cell movement

� 6) Biofilm



Interactions with human epithelial cells in vitro

� Adherence to cultured human epithelial cell lines¡ alveolar, bronchial, laryngeal, oral, conjunctival cervical

tissues

� pilA (a putative type IV pilus gene) **



Risk factors



Diagnosis



� Gold standardà culture + ve B. pseudomallei

� Gram stain : non specific

� Catalase , oxidase : +ve (Glucose,maltose,10%lactose)

� Techniques¡ 1) การเพาะเชื อ (culture-based methods)

¡ 2) การตรวจหาแอนตเิจน (antigen detection)

¡ 3) การตรวจหาแอนตบิอดี (antibody detection)

¡ 4) วิธีการทดสอบทางโมเลกลุ (molecular methods)



การเพาะเชื ้อ (Culture-based methods)

� Ashdown selective medium¡ ซึ งเปน tryptase soy agar ที มีglycerol, crystal violet, neutral red,

และ gentamicin (4 mg/liter)

¡ Contaminate Klebsiella spp., P. aeruginosa, Enterococcus

faecalis, B. cepacia, และ Serratia marcescens

� Modified Ashdown selective medium

� Blood agar

� MacConkey agar



Ashdown’s selective mediumin 24 hr at 37 c , sweet earthy smell



24 hr > 48 hr

Blood agar



MacConkey agar



� The automatic BacT/Alert system

� Duration untive cultured¡ <24 hràmortality rate 73.7%

¡ >24 hràmortality rate 40.9%

Tiangpitayakorn C, Songsivilai S, Piyasangthong N, Dharakul T. Speed of detection of Burkholderia pseudomallei inblood cultures and its correlation with the clinical outcome. Am J Trop Med Hyg 1997 Jul;57(1):96-9



การตรวจหาแอนตเิจน ( Antigen detection)

� Latex agglutination : for culture identification

� Direct immunofluorescence : for direct specimen

(Antibody



การตรวจหาแอนตบอด ( Antibodydetection)

� IHA ( Indirect Hemagglutinin)

� Sense 60-80% , spec 80-90%

� Cutoff titer

¡ Australia 1 : 40¡ Thailand 1: 160

� False negative : acute sepsis , and significant background rates of positive antibody

วิธการทดสอบทาง มเลกล (Molecular



วธการทดสอบทาง มเลกุล (Molecularmethods)

� Non practical

� Detect primers targeting regions¡ 23S rRNA, 16S RNA, และ 16S กับ 23S RNA



Clinical features



� 40-60 yrs

� M : F 1.4:1

� Incubation period : 2 days – 26 yrs

� Acute / subacute / chronic

� Abscess formation :¡ brain, prostate, joint, skin, parotid gland, intraabdominal

mesenteric root, mycotic aneurysm of iliac, subclavian a.

� The great imitator



Clinical manifestations

� Disseminated septicemic form

� Non-disseminated septicemic form

� Multifocal localize form

� Localized form� Transient bacteremic form

� Probable form

� Subclinical form



Sites of infection



CLINICAL MANIFESTATIONS

® Pneumonia — the most common ,range froman acute subacute or chronic

® Skin ulcers or abscesses

® Genitourinary

® Septic arthritis or osteomyelitis

® Encephalomyelitis

® Abscesses within organs — Abscesses ininternal organs are well recognized, especially in the spleen, kidney, prostate and liver



Pulmonary involvement

� Acute : alveolar, consolidation

� Subacute / chronic : mixed

¡ Nodular

¡ Patchy

¡ Reticulonodular

DDx Staph aureus



Pulmonary melioidosis



Pulmonary involvement

� Patho : necrosis, chronic inflammation, caseousgranulomatous

� Risk : TB , CA lung, cystic fibrosis



Liver and spleen



Typical melioidosis abscess

� Multiple

� Cystic hypoechoic

� Target like, bull eye

� Internal septum “ Cart wheel appearance”� Splenic involvement



ENT

� Parotid gland abscess

� Pharyngotonsilitis

� Sinusitis



Parotid abscess



Prostatic abscess



Bone and Joint

� DM (37%), Renal failure (9%)

� Imaging nonspecificà culture



Subhadrabandhu T, Prichasuk S, Sathapatayavongs B. Localised melioidotic osteomyelitis. J Bone JointSurgBr 1995 May;77(3):445-9



Cutaneous melioidosis



Septicemic melioidosis



CNS

� Encephalitis

� Brain abscess

� Meningitis¡

CSF aseptic meningitis, resemble TB



Encephalomyelitis



Cardio

� Pericarditis

� Pericardial effusion

� Myocarditis

� Endocarditis



Treatment

� 1) Intensive phase therapy

� 2) Eradication/maintenance therapy



Intensive phase therapy

Severe melioidosis ( Wirongrong Chierakulและคณะ)

� 1) BT > 38 องศาเซลเซียส หรือ<36 องศาเซลเซียส

� 2) PR > 90 bpm

� 3) RR > 20 tpm or PaCo2 > 32 mmHg � 4) WBC > 12000* 106 เซลล์ต่อลิตร หรอื band form>10%

� 5) Organ dysfunction (oliguria ,lactic acidosis)

� 6) Hypotension; SBP< 90 mmHg



Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management.Clin Microbiol Rev 2005 Apr;18(2):383-416



Reference

� 1. White,N.J.,D. A .Dance,W .Chaowagul,Y . Wattanagoon,V . Wuthieka-nun,andN.Pitakwatchara.1989.Halvingofmortalityof severemelioidosisbyceftazidime. Lancet ii:697–701.

� 2. Sookpranee,M.,P.Boonma,W .Susaengrat,K .Bhuripanyo,andS.Pun- yagupta.1992.Multicenterprospectiverandomizedtrialcomparingcefta-zidimeplusco-trimoxazolewithchloramphenicolplusdoxycyclineandco-trimoxazolefortreatmentofseveremelioidosis. Antimicrob. Agents Chemother. 36:158–162.

� 3.Suputtamongkol,Y .,A .Rajchanuwong,W .Chaowagul,D. A .Dance,M.D.Smith,V . Wuthiekanun,A .L. Walsh,S.Pukrittayakamee,andN.J. White.1994.Ceftazidimevs.amoxicillin/

clavulanateinthetreatmentofseveremelioidosis.Clin.Infect.Dis. 19:846–853.� 4. Simpson,A .J.,Y .Suputtamongkol,M.D.Smith,B.J. Angus,A .Rajanu- wong,

V . Wuthiekanun,P. A .Howe,A .L. Walsh,W .Chaowagul,andN.J. White. 1999. Comparisonofimipenemandceftazidimeastherapyforseveremelioidosis.Clin.Infect.Dis.29:381–387.

� 5. Thamprajamchit,S.,P.Chetchotisakd,andB.Thinkhamrop. 1998.Ce-foperazone/sulbactam co-trimoxazolevsceftazidime co-trimoxazoleinthetreatmentofseveremelioidosis:arandomized,double-

blind,controlledstudy .J.Med. Assoc.Thai. 81:265–271.� 6. Chetchotisakd,P.,S.Porramatikul,P.Mootsikapun,S. Anunnatsiri,andK .Kean.

2001.Randomized,double- blind,controlledstudyofcefopera-zonesulbactampluscotrimoxazoleversesceftazidimepluscotrimoxazoleforthetreatmentofseveremelioidosis. Clin.Infect.Dis. 33:29–34.

� 7. W .Chaowagul,unpublished data



� Ceftazidime 30–50 mg/kg IV q8h or� IMP 20 mg/kg IV q8h

� Amox-clav 27 mg/kg IV q4h

Minimum 10 d or improve Extended 4-8 wks

extensive pulmonary disease,

deep seated collections or organ abscesses,osteomyelitis, septic arthritis or

neurologic melioidosis

Addi i f TMP SMX



Addition of TMP-SMX

¯ excellent tissue penetration ¯ neurologic, prostatic, and bone and

joint melioidosis.

¯ Folic acid (0.4 to 5 mg PO daily)

Adjunctive therapy in intensiveh



phase

� Abscess drainage

di i / i h



Eradication/Maintenance therapy

� Doxycycline 4 mg/kg bid + TMP-SMX 10 mg/kg and50 mg/kg bid * 20wks

f



Reference

� 1. Rajchanuvong,A .,W .Chaowagul,Y .Suputtamongkol,M.D.Smith,D. A .B.Dance,andN.J. White.1995. Aprospectivecomparisonofco-

amoxiclavandthecombinationofchloramphenicol,doxycycline,andco-

trimoxazolefortheoralmaintenancetreatmentofmelioidosis.Trans.R .Soc.Trop.Med.Hyg. 89:546–549.

� 2. Chaowagul,W .,A .J.Simpson,Y .Suputtamongkol,M.D.Smith,B.J. Angus,andN.J. White.

1999. Acomparisonofchloramphenicol,tri-methoprim-sulfamethoxazole, anddoxycycline withdoxycyclinealoneasmaintenancetherapyformelioidosis. Clin.Infect.Dis. 29:375–380.

� 3. Chetchotisakd,P.,W .Chaowagul,P.Mootsikapun,D.Budhsarawong,andB.Thinkamrop.2001.Maintenancetherapyofmelioidosiswithciprofloxa-cinplusazithromycincomparedwithcotrimoxazoleplusdoxycycline. Am.J.Trop.Med.Hyg. 64:24–27.

� 4. W .Chaowagul,unpublished data



� Doxy 2 mg/kg bid * 20 wks;

� TMP-SMX 5 mg/kg (TMP) bid *20 wks

� Chloramphenicol 10 mg/kg q6h * 8 wks;

� except in patients with osteomyelitis orneurologic melioidosis, in whom eradicationtherapy for six months is recommended

A ibi i i



Antibiotic resistant

� 3rd-generationcephalosporins

� Penicillins

� Rifamycins� Aminoglycoside

� Quinolones � Macrolides

Ri k f R l



Risk of Relapse

® Poor compliance **® ≤8 weeks of total therapy

® Severe disease

® Multifocal distribution® Amoxicillin-clavulanic acid

® Relapse 13%, >50% within 1 yr

F t t t t



Future treatment

V i d l t



Vaccine development

� DNA vaccine� Attenuated vaccine

� Conjugated vaccine

� Heterologous vaccine



T H A N K S F O R A T T E N T I O N

melioidosisj

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