He suffered from diabetes mellitus type 2, but was otherwise heal

He suffered from diabetes mellitus type 2, but was otherwise healthy. In the previous years he had complained of intermittent abdominal pain, but both an ultrasound and X-ray performed the previous year were normal. He did not return to Sri Lanka or visit other tropical areas in the period of 2005 to 2007. At admission his blood samples showed white blood cell count (WBC) of 10.7 × 109 L−1 and the C-reactive protein (CRP) level was 100 mg/L. Abdominal computed tomography (CT) scan demonstrated a splenic abscess (Figure

1A), and he was transferred to the regional hospital for further treatment. The abscess was drained, and treatment with antibiotics was started. A fistula between the spleen and colon was eventually diagnosed, and a splenectomy was performed. Histological examination of biopsies from colon and spleen demonstrated subacute inflammation,

fibrosis, and necrosis. One week after surgery he developed a subphrenic abscess Antidiabetic Compound Library that was drained successfully. Five days after admission there was growth in blood culture of a nonfermentative, oxidase-positive, gram-negative rod with bipolar staining. The bacteria grew on blood and lactose agar. After some days of culture, the colonies appeared large and dry with a typical wrinkled surface. The bacteria isolated from blood were identified as Burkholderia pseudomallei by the Vitek 2 system with LDK378 solubility dmso 96.4% probability. Sequencing of the 16S rRNA gene demonstrated ASK1 DNA sequences identical to sequences of B pseudomallei in GenBank. Later, the bacteria were isolated from both the splenic and the subphrenic abscesses. The commercial biochemical test API 20 NE (BioMérieux, Marcy l’Etoile, France) supported the identification. The rod grew at 42°C, which is in contrast to the characteristics of Burkholderia mallei. The minimum inhibitory concentration (MIC) values obtained from the E-tests (AB Biodisk, BioMérieux) performed on the isolates are summarized in Table 1. The patient was treated with antibiotics intravenously for a total of 6 weeks.

At the admission to hospital he initially received cefuroxime and metronidazole, but because of lack of clinical response this was changed to meropenem after a few days. For the last couple of weeks of the treatment he received piperacillin-tazobactam according to susceptibility data, available before the bacteria were identified. Although piperacillin-tazobactam appears to be effective in vitro, there is little clinical experience on which to recommend their use.1 However, the clinical condition of the patient improved during this period, so there is reason to believe that also in vivo susceptibility existed for this antibiotic. He was thereafter transferred back to his local hospital and received eradication therapy with trimethoprim-sulfamethoxazole (TMP-SMX) and doxycycline for a total of 20 weeks with gradual improvement of his clinical condition.

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