A 12-year-old boy presented with fever and cough of 12 days and painful skin lesions on legs for two days. He did not have any pre-existing medical illness, history of contact with soil, or groundwater. He presented in July, which is monsoon season in coastal Karnataka. On examination, his weight was 30 kg (75th percentile), height was 130 cm (50th to 75th centile), and vitals were stable. Oral examination revealed red and swollen tonsils with an exudative membrane on the medial surface. He had multiple erythematous, tender, nodular lesions of 10-20 mm size on bilateral lower limbs consistent with erythema nodosum. Systemic examination was unremarkable. Baseline blood tests showed hemoglobin of 10.5 g/dL, total leukocyte count of 11.8×109/L (P 80%, L 16%), platelet count of 241×109/L, erythrocyte sedimentation rate of 42 mm/h and C-reactive protein of 96 mg/dL. Throat swab and blood culture were sent, and he was prescribed intravenous amoxicillin/clavulanic acid and amikacin. His throat swab isolated Burkholderia pesudomallei, hence antibiotics were changed to intravenous ceftazidime (120 mg/kg/day). The child improved with resolution of symptoms over the next four days. He received ceftazidime for 10 days and was discharged on oral trimethoprim-sulfamethaxazole (6mg/kg of trimethoprim) for three months. The child is well at six month follow-up.

Melioidosis, caused by soil saprophyte B. pseudomallei, is an endemic infection in India [1]. Due to diverse clinical manifestation and lack of routine bacteriological detection methods, melioidosis stays under-diagnosed and under-reported [2]. Typical clinical presentation of melioidosis includes suppurative lesions in head and neck, soft tissue infection, pneumonia, and septicemia [3,4]. Our patient presented with membranous tonsillitis and erythema nodosum, common entities in pediatric practice, but B. pseudomallei as the etiologic agent for the same has not been previously reported. Two patients with pharyngitis with pharyngeal culture-positive, and a single patient with urticarial rash and blood culture positive for B. peusdomallei has been reported by Lumbiganon, et al. [4]. A study by Wuthiekanun, et al. [5] reported 100% specificity and 36% sensitivity of throat swab culture for melioidosis. Due to low sensitivity, throat swab warrants the need for adjunctive tests.

A high index of suspicion is required to diagnose melioidosis due to its varied presentation, especially in the presence of predisposing conditions like exposure to soil, water, rainy season, or an immunocompromised state.

Acknowledgements: Dr Sowmini P Kamath and Dr K Jayashree, of our department for case management.

Contributors: SSR, NK: Both authors were involved in case management, and manuscript preparation.

Funding: None; Competing interest: None stated.

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