Disseminated melioidosis complicated by infective endocarditis necessitating aortic and mitral valve replacement: a case report

Background Melioidosis is caused by Burkholderia pseudomallei , a saprophytic, intracellular, Gram-negative bacteria commonly found in soil and stagnant water in endemic areas of South-East-Asia and Australia. Melioidosis can present acutely with pneumonia, bacteraemia or with chronic disseminated infection involving distant organs. It is typically managed with an intensive phase of intravenous antibiotics followed by a consolidation phase with oral antibiotics, with length determined by the site and burden of infection. Case presentation A 78-year-old white, British man presented with shortness of breath and fever 2 weeks after returning from Thailand. A SARS-CoV-2 lateral flow test was positive, and the patient was treated initially for community acquired pneumonia. The patient failed to respond to empirical therapy and had ongoing fevers with an oxygen requirement. Burkholderia pseudomallei was first isolated from blood cultures on day 7 of admission and subsequently on days 10 and 14. A pansystolic murmur was detected with a transoesophageal echocardiogram demonstrating severe mitral stenosis with mobile masses seen on both aortic and mitral valves and within the left atrium. Additionally, there was disseminated infection with culture positive cutaneous disease and prostatic abscesses. The patient was successfully treated with 12 weeks of ceftazidime and high dose co-trimoxazole, before stopping therapy due to desquamating rash. The patient underwent replacement of both aortic and mitral valves three months after initial presentation. Valve cultures were negative, and the patient has remained well with suppressed inflammatory markers upon follow up. Conclusions Infective endocarditis is a rare complication of melioidosis and is usually managed conservatively with antibiotics and without surgery. The patient had no specific risk factors for melioidosis such as diabetes or immunosuppression but noted sandstorms while in Thailand which may have led to aerosolisation and pulmonary infection. This is the first case to our knowledge, of native valve endocarditis in a patient with melioidosis requiring bivalvular replacement surgery. This case highlights the importance of recognising potential complications associated with cardiovascular manifestations of melioidosis.