M farmer from Assam prese...

A 68 year old male farmer from Assam, presented with Fever, Oligo-arthritis weight loss since two months. He is poorly control Diabetic with CAD. Alcohol consumption of about 60g/day for 30years and a smoker with 15pack years. He was febrile, BMI was 26.49kg/m2. He had pallor, fundus showed moderate non-proliferative diabetic retinopathy, and pedal edema, His systemic examination was normal. MSK examination gait was antalgic, restrictions and tenderness noted over right knee, left ankle, and both elbows. The Right Calf & thigh were tender. Hb was 7.2g/dl, total leukocyte counts 12900/cumm and platelet count 1.16 lakhs/cumm. The PBS picture was suggestive of Iron deficiency anemia. ESR- 120mm/hour, CRP- 384mg/dl & serum ferritin- 1246ng/ml. HbA1C of 7.11%. AST-172u/l and ALT 108u/l, GGT 242u/l. The workup for dengue, malaria, scrub typhus, Brucella, and another blood culture was negative. Serum procalcitonin was raised. Ultrasound showed Right knee and left ankle effusion with synovitis. The tumor markers & myeloma workup was normal With high levels of D-dimer- 3.37mcg (N<0.5). PET scan showed lesions involving left lobe of prostate gland, loculated collection Right gastrocnemius muscle with collection in right knee joint. Under ultrasound guidance purulent fluid aspirated from Right gastrocnemius muscle. Pus culture showed gram negative bacteria with characteristic bipolar staining safety pin appearance, rough and corrugated colonies with metallic sheen on blood agar, The identified organism was Burkholderia pseudomallei. The same was grown from blister aspirate and prostatic abscess too The patient was successfully treated with Meropenem and Ceftazidime for 28 days then oral Septran and Doxycycline for six months.