Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 3839  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Resource Links
  »  Similar in PUBMED
 »Related articles
  »  Article in PDF (1,591 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

  In this Article
 »  Abstract
 » Case Report
 » Discussion
 » Conclusion
 »  References
 »  Article Figures

 Article Access Statistics
    PDF Downloaded119    
    Comments [Add]    
    Cited by others 3    

Recommend this journal


Table of Contents    
Year : 2018  |  Volume : 66  |  Issue : 4  |  Page : 1100-1105

Melioidosis mimicking tuberculous vertebral osteitis: Case report and review of literature

1 Department of Neurosurgery, Institute of Neurosciences, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
3 Department of Radiology, Apollo Hospitals, Chennai, Tamil Nadu, India
4 Department of Microbiology, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Web Publication18-Jul-2018

Correspondence Address:
Dr. Anil Pande
Department of Neurosurgery, Institute of Neurosciences, Apollo Hospitals, Chennai, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.236976

Rights and Permissions

 » Abstract 

Whitmore's disease or melioidosis is an infectious disease caused by Burkholderia pseudomallei. The reported cases are but the tip of the iceberg. This pathogenic saprophyte is commonly found in wet soil and water. An accidental or occupational exposure (in field workers, farmers, gardeners or villagers) to B. pseudomallei contaminated soil or pooled water is the primary source of infection. Neurosurgeons need to consider this as a possible rare cause of back pain and possible neurological deterioration. A diabetic type 2 rice farmer with severe lumbago and fever, misdiagnosed as vertebral tuberculous osteitis based on his radiological findings, was confirmed to harbour Burkholderia Pseudomallei, which was diagnosed using laboratory cultures. He made a remarkable recovery with antibiotic therapy. The empiric anti-tuberculous (ATT) drugs were stopped. The rare differential diagnosis of melioidosis should be thought of in diabetic patients with a psoas abscess and vertebral osteitis, especially in rice farmers from endemic regions that includes India.

Keywords: Burkholderia Pseudomallei, low back pain, melioidosis, psoas abscess, spinal infection, vertebral osteitis, Whitmore's disease
Key Message: Vertebral osteitis with paraspinal and psoas abscess can be caused by Burkholderia Pseudomallei. Reported cases of melioidosis or Whitmore′s disease are just the tip of the iceberg. Neurosurgeons need to consider this as a possible rare cause of lumbago often associated with neurological deterioration. Empiric anti-tuberculous (ATT) drugs should be used cautiously, especially in diabetic rice farmers. Reporting these rare cases is essential to assess the true burden of this serious, and occasionally, lethal illness.

How to cite this article:
Pande A, Nambi P S, Pandian S, Subramanian S, Ghosh S. Melioidosis mimicking tuberculous vertebral osteitis: Case report and review of literature. Neurol India 2018;66:1100-5

How to cite this URL:
Pande A, Nambi P S, Pandian S, Subramanian S, Ghosh S. Melioidosis mimicking tuberculous vertebral osteitis: Case report and review of literature. Neurol India [serial online] 2018 [cited 2022 Dec 1];66:1100-5. Available from: https://www.neurologyindia.com/text.asp?2018/66/4/1100/236976

Whitmore's disease or melioidosis is an infectious disease caused by Burkholderia pseudomallei, a pathogenic saprophyte commonly found in wet soil and water. An accidental or occupational exposure to B. pseudomallei present in the contaminated soil or pooled water is the primary source of infection. The manifestations of vertebral osteitis with paraspinal and psoas abscess, caused by Burkholderia Pseudomallei, in a diabetic rice farmer, who was misdiagnosed as having tuberculous affliction of the spine, is being reported. The patient was erroneously being administered empiric anti-tuberculous (ATT) medication

 » Case Report Top

A 40-year old, type 2 diabetic farmer from a village near Tirupati, Andhra Pradesh, India, presented with excruciating low back pain and intermittent high-grade fever of 45-days duration. The patient reported pain involving both the lower extremities with a high intensity specifically on the right side. However, no typical history of radiculopathy or myelopathy was found. There were no neurological deficits. His single leg raising test was positive bilaterally, but was nonconclusive due to the presence of severe pain. His past medical history revealed the presence of pulmonary tuberculosis infection 5 years ago for which he had been administered a 9-month course of essential anti-tuberculous (ATT) medications. His coronal magnetic resonance imaging (MRI) scan of the lumbar spine with contrast (done in another medical facility) revealed enhancing lytic areas in the L4 vertebral body and the right iliac bone, associated with peripherally enhancing, centrally necrotic, multi-loculated, right paraspinal abscess, with psoas and right gluteal soft tissue components [Figure 1]a and [Figure 1]b.
Figure 1: (a and b) Pretherapy: Coronal post-contrast T1 fat suppressed images show enhancing lytic lesions in the right half of L4 vertebral body and right iliac bone; peripherally enhancing centrally necrotic right paraspinal, right psoas and right gluteal soft tissue components are also noted

Click here to view

Based on these radiological findings, a diagnosis of tuberculosis was made and ATT was started empirically.

On examination, a paraspinal swelling and a left knee joint effusion were observed. Upon admission to our hospital, a computed tomographic (CT)/ultrasound (USG)-guided biopsy was planned. As the USG examination revealed a right paraspinal fluid collection with freely mobile internal echoes, an USG guided aspiration was performed under local anaesthesia. The aspirate revealed frank pus. Microscopy showed gram negative bacteria [Figure 2] and laboratory culture tests of the pus sample revealed the growth of Burkholderia pseudomallei in both blood [Figure 3] and MacConkey agar medium [Figure 4].
Figure 2: Microscopy showing Gram negative bacilli

Click here to view
Figure 3: Growing colonies of  Burkholderia pseudomallei Scientific Name Search n blood agar

Click here to view
Figure 4: Growing colonies of Burkholderia Pseudomallei on MacConkey agar

Click here to view

On blood culture tests, the two aerobic test tubes also showed positive results and the same microorganism was identified using the matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). The organism was found to be sensitive to antibiotics like ceftazidime, meropenem, and trimethoprim–sulfamethoxazole. No other mycobacterial and fungal growth were observed on the culture. Follow-up test cultures also revealed negative results for other microorganisms. The gene Xpert MTB (Mycobacterium tuberculosis) for tuberculosis was negative. The rheumatoid arthritis factor and human leucocytic antigen (HLA) B27 were also negative. Laboratory findings revealed significant neutrophilic leucocytosis with toxic granules and a white cell count of 18.35 × 103/mm 3, an erythrocytic sedimentation rate of 140 mm/hr in the first hour, and a haemoglobin level of 7.9 gm%. The glycosylated haemoglobin was 10.9%. The serum sodium, potassium and chloride levels were found to be 130, 4.2 and 90 mEq/l, respectively. The serum alkaline phosphatase level was 222 U/l. After treatment with antibiotics, regression of the primary psoas abscess was noted. He was managed conservatively, as has been the reported norm for the disease. Suggestions of the infectious disease specialist were also incorporated into the patient's treatment plan. Empiric ATT treatment started in the earlier hospital was aborted. The patient was started on intravenous ceftazidime (2 gm thrice daily) along with oral trimethoprim (TM)-sulfamethoxazole [SMX] (80 mg TMP with 400 mg SMX) and doxycycline (100 mg twice daily). Prolonged antibiotic therapy has been recommended in case of chronic infections. An intensive phase of therapy using intravenous ceftazidime for 6 weeks was given in view of the spinal involvement, followed by oral maintenance therapy with doxycycline and TM-SMX. He was advised to continue the antibiotic therapy for one year. His diabetic treatment was optimised. The glycosylated haemoglobin was reduced to 5.3% and white cell counts also came down to 11.3 × 103/mm 3. Other laboratory parameters were also found to normalise gradually. Finally, the patient was discharged on medication. His visual analogue scale (VAS) pain score reduced from 9 to 3 and he did not have any neurological deficits at the time of discharge. The follow-up MRI of the lumbar spine with contrast after 6 weeks of antibiotic therapy revealed significant resolution of the right paraspinal and gluteal soft tissue components, with residual right iliac bone disease persisting [Figure 5]a and [Figure 5]b.
Figure 5: (a and b) Posttherapy: Follow up MRI of the lumbar spine with contrast after 6 weeks of initiation of treatment reveals significant resolution of the right paraspinal and gluteal soft tissue components with residual right iliac bone disease

Click here to view

 » Discussion Top

Melioidosis, also known as Whitmore's disease, is an infectious disease caused by a Gram-negative bacterium called Burkholderia Pseudomallei. B. Pseudomallei is an environmental saprophyte which is commonly found in wet soil and water. It was first described by Alfred Whitmore and C. S. Krishnaswami in 1911 as an undescribed infective disease occurring among the population of Rangoon, Burma.[1] Glanders caused by Burkholderia mallei is a disease of horses, but humans can also be infected.[2]

It is described as an emerging infectious disease with a mortality rate of 58%.[3] Majority of patients suffering from melioidosis are found to be diabetic (38-75%), and exposure to the contaminated water or soil is the root cause of affliction in 39-85% of patients. Commonly, rice farmers who have an increased exposure to contaminated soil and pooled water are prone to this infection.[4] The other predisposing factors cited are pre-existing renal disease, thalassemia, and an occupational exposure. An increase in the infectivity rate shows a strong correlation with rainfall.[5]

Contamination of non-chlorinated water supply has been found to be an underreported causative factor.[6] The rare transmission of the disease via breast feeding to neonates has been noted.[7] Even though neonatal infection is possible, clinical reports of neonatal cases suffering from melioidosis are rare.[8] The disease is reported to be endemic in the Indian subcontinent, where it is said to be an emerging disease with the few reported cases likened to be the tip of the iceberg.[9],[10] In recent years, melioidosis has also been reported globally in different countries like Australia, Malaysia, and Africa.[6],[11],[12] Melioidosis is commonly underdiagnosed and underreported in India.[13] In India, cases suffering from melioidosis have been largely reported from Tripura, Kerala, Orissa, Tamil Nadu, and Maharashtra.[14] The seroprevalance rates of 7% have been found from rice growing areas near Vellore.[9] Furthermore, travel history has to be taken into consideration, as melioidosis can be seen in distant non-endemic regions brought there by travellers or tourists.[15],[16]

Melioidosis is characterised by abscess formation in all parts of the body.[17] It is classified as acute or chronic (based on the duration of symptoms); bacteremic or non-bacteremic (based on the isolation of bacterium from blood culture); and, localized (or focal) or disseminated (or multifocal, based on the organ involvement) melioidosis. Although, melioidosis is found be to focal in 78.5% of cases, multifocal melioidosis is more frequently reported (28.5%).[6] The mortality rates are found be to be high (20-40%), and relapse can occur in 6-13% of patients.[6] Generally, all organ systems are found be involved in patients with melioidosis, including the head and neck.[18],[19] Neurological involvement is seen in approximately 7% of cases, and brain abscess, meningoencephalitis, and empyema, with both cranial and spinal involvement have been reported.[18],[19],[20],[21],[22],[23] A distinct neurological syndrome characterised by peripheral motor weakness, brain stem encephalitis, and respiratory failure is also seen.[22] In a recent study involving 95 confirmed cases of melioidosis from western coastal India, pneumonia was seen in 32.6% of cases, musculoskeletal involvement in 20%, melioidotic lymphadenopathy in 7.4%, and dental abscess in 6.3% of the patients.[24] Rarely, in about 1-2% of cases, it can cause mycotic aneurysms.[25] Another larger study from Australia found that 81% of infections occurred commonly during the monsoon season.[11]

As melioidosis is probably not rare, it is underreported in India.[24] Involvement of the musculoskeletal system is infrequent and this low rate of involvement is attributed to the relatively low blood supply of the musculoskeletal system.[6] Spinal infection is classically defined as an infectious disease affecting the vertebral body, intervertebral disc and/or adjacent paraspinal tissue, although in melioidosis, involvement of the vertebral column is rare.[26],[27] Melioidotic psoas abscess has also been reported.[28] Vertebrae, predominantly in the lumbar region, are the most commonly affected locations in haematogenous osteomyelitis. Generally, the infection spreads to the proximate vertebral bodies and the intervening disc by the ascending and descending branches of posterior spinal arteries, while the isolated involvement of distant vertebral bodies is infrequent.[29] In recent years, the incidence rate of vertebral osteomyelitis has significantly increased.[30],[31],[32]

Even though patients may present a year after the bacteraemia episode, the pathogen isolated from cultures can guide the required antibiotic therapy.[30] Clinically, pyogenic spinal infections present as excruciating back pain, which is more severe at night.[30] Spinal involvement is rare in pyogenic osteomyelitis, whereas the most common differential diagnosis is tuberculosis.[33] The most frequent causative microorganisms for pyogenic infections are Gram positive bacteria like Staphylococcus aureus.[34] In India, lumbago is often treated with empiric ATT in patients with vertebral osteitis, that is confirmed using imaging and clinical findings. Furthermore, 60-90% of these patients may not have lesions anywhere else in the body. In the clinical presentation of melioidosis, most patients are found to be diabetic; and excruciating low back pain and high temperature are the frequent symptoms.

Pott's spine has been wrongly and empirically diagnosed in cases which could eventually turn out actually to be any of the following entities: malignant primary spine tumours, metastatic spine tumours, nocardosis, actinomycosis, candidiasis, cryptococcosis, histoplasmosis, paracoccidioidomycosis, septic arthritis, tuberculosis caused by Mycobacterium kansasii, and spinal cord abscess. Granulomatous diseases like  Brucellosis More Details and rarely, atypical tuberculosis, Mycobacterium avium Scientific Name Search  complex (MAC) and Mycobacterium avium intracellulare (MAI) can rarely mimic or be mimicked by melioidosis.[35],[36],[37] The most common predisposing factors for the occurrence of melioidosis are spinal sepsis and reduced neutrophil function secondary to type 2 diabetes mellitus, obesity, alcoholism, thalassemia, chronic renal and lung disease, steroid use, immunosuppression in transplant patients and occupational exposure to pooled water and wet soil.[5],[14],[38] Before their clinical manifestations start, most of the patients remain clinically asymptomatic for 2-6 weeks.[34] An impaired or reduced neutrophil function is the central factor for increased susceptibility to infection, as it leads to co-infection or concurrent infection with tuberculosis. Along with B. pseudomallei, intracellular pathogens like Mycobacterium tuberculosis, non-typhoid  Salmonella More Details, and leptospirosis have been reported together, co-infecting a single lesion.[39],[40],[41] A high index of suspicion has been advocated in pulmonary and extra-pulmonary tuberculosis-like presentation in diabetic and immunocompromised subjects where melioidosis has been likened to be a great mimic.[28]

The biochemistry and microbiology of melioidosis has been studied extensively and reported. Biomarkers like complete blood count, C-reactive protein, erythrocyte sedimentation rate, and procalcitonin are utilised to investigate and monitor the treatment response.[42] On radiological examination, multiple abscesses exhibit a Swiss cheese or honeycomb appearance. Nontuberculous pyogenic vertebral osteitis most commonly involves the lumbar vertebrae (58%), followed by the thoracic (30%) and cervical (11%) vertebrae.[43] In contrast, tuberculous vertebral osteitis frequently involves the dorsal spinal vertebrae. Plain radiographs may be normal, as was seen in the present case. The sensitivity of plain radiographs in diagnosing this disorder is only 59%, and reduction in the disc height and end plate abnormalities are noted in the advanced stages of the ailment.[44] MRI has a sensitivity of 96%, which is better than the sensitivity of technetium 99m-hydroxydiphosphonate (HDP) bone scanning and Gallium 67 scanning.[44] An MRI assessment of the disc height and signal intensity changes clearly define the presence of nuclear clefts, vertebral signal intensity alterations, end plate erosions on T1 weighted images, and the presence of paraspinal and epidural inflammation.[45] Iliopsoas abscess can have a varied aetiology and should not always be generalized to be seen as a part of the tuberculous pathology. In fact, 21.5% of the patients harbouring an iliopsoas abscess are found to be having a polymicrobial aetiology, and an abscess is found to be having a spinal origin in a majority of these patients.[46],[47],[48] The follow-up MRI scans show a reduction in the soft tissue involvement, but persisting tissue and bony findings may be seen in patients who have responded well to treatment.[49] CT or ultrasound or both have been used to guide the aspiration of the iliopsoas abscess with good results.[50],[51] A controlled treatment study reported that antibiotic therapy for at least 6 weeks or longer is highly recommended comparable to 12 weeks of therapy.[52]

Although management protocols for spinal infections are standardised, spinal melioidosis still remains an unchartered terrain and requires validation of the guidelines, mainly for the type of antibiotics to be administered and their duration of therapy. Surprisingly, repeated environmental exposure does not result in the development of cellular or humoral immunity.[5],[53] The exact diagnosis of clinical cases of meliodosis along with the reporting and recording of these cases is an important need of the hour, as a missed or mistaken diagnosis and an erroneous treatment can result in a fatality.[36] Vaccines are being developed and may be useful in high risk patients (for example, in diabetic rice farmers) and in endemic regions.[2],[4]

 » Conclusion Top

Melioidosis is an emerging infectious condition and is underreported. It is a great mimic and can be a life-threatening condition. As a tropical saprophyte, Burkholderia pseudomallei lives in wet soil and water. Endemic exposures are frequent in villagers, farmers, and field workers. ATT in vertebral osteitis should be used cautiously. As the treatment required for melioidosis is radically different, waiting for a response to empiric ATT therapy can be lethal. Isolation of the pathogen from the lesion using CT and/or ultrasound guided biopsy and further laboratory analysis can guide therapy in these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


We would like to acknowledge the help provided by Ms Rathi Priya Annan, MS (Neuroscience), in the preparation of the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Whitmore A, Krishnaswami CS. A hitherto undescribed infective disease in Rangoon. Indian Med Gaz 1912;47:262-7.  Back to cited text no. 1
Gilad J. Burkholderia mallei and Burkholderia pseudomallei: The causative micro-organisms of glanders and melioidosis. Recent Pat Antiinfect Drug Discov 2007;2:233-41.  Back to cited text no. 2
Jesudason MV, Anbarasu A, John TJ. Septicaemic melioidosis in a tertiary care hospital in south India. Indian J Med Res 2003;117:119-21.  Back to cited text no. 3
Suputtamongkol Y, Chaowagul W, Chetchotisakd P, Lertpatanasuwun N, Intaranongpai S, Ruchutrakool T, et al. Risk factors for melioidosis and bacteremic melioidosis. Clin Infect Dis Off Publ Infect Dis Soc Am 1999;29:408-13.  Back to cited text no. 4
Cheng AC, Currie BJ. Melioidosis: Epidemiology, pathophysiology, and management. Clin Microbiol Rev 2005;18:383-416.  Back to cited text no. 5
Zueter A, Yean CY, Abumarzouq M, Rahman ZA, Deris ZZ, Harun A. The epidemiology and clinical spectrum of melioidosis in a teaching hospital in a North-Eastern state of Malaysia: A fifteen-year review. BMC Infect Dis 2016;16:333.  Back to cited text no. 6
Ralph A, Mcbride J, Currie BJ. Transmission of Burkholderia pseudomallei via breast milk in Northern Australia. Pediatr Infect Dis J 2004;23:1169-71.  Back to cited text no. 7
Ang YM. Neonatal meliodosis: Very rare but be aware. Med J Malaysia 2005;60:99-102.  Back to cited text no. 8
Kang G, Rajan DP, Ramakrishna BS, Aucken HM, Dance DA. Melioidosis in India. Lancet 1996;347:1565-6.  Back to cited text no. 9
Dance DA. Melioidosis as an emerging global problem. Acta Trop 2000;74:115-9.  Back to cited text no. 10
Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis 2010;4:e900.  Back to cited text no. 11
Birnie E, Wiersinga WJ, Limmathurotsakul D, Grobusch MP. Melioidosis in Africa: Should we be looking more closely? Future Microbiol 2015;10:273-81.  Back to cited text no. 12
John TJ, Jesudason MV, Lalitha MK, Ganesh A, Mohandas V, Cherian T, et al. Melioidosis In India: The tip of the iceberg? Indian J Med Res. 1996;103:62-5.  Back to cited text no. 13
John GT, Ahmed I, Jacob CK, Jesudason MV, Lalitha MK. Melioidosis in a renal transplant recipient. Transplantation 2003;76:262.  Back to cited text no. 14
Jenkins DR, Lewis AM, Strachan CJ. Imported melioidosis in a British native. J Infect 1990;21:221-2.  Back to cited text no. 15
Shrestha N, Sharma S, Khanal B, Bhatta N, Dhakal S. Melioidosis imported into Nepal. Scand J Infect Dis 2005;37:64-6.  Back to cited text no. 16
White NJ. Melioidosis. Lancet 2003;361:1715-22.  Back to cited text no. 17
Kuan YC, How SH, Ng TH, Fauzi AR. The man with the boggy head: Cranial melioidosis. Singapore Med J 2010;51:e43-45.  Back to cited text no. 18
Lim WK, Gurdeep GS, Norain K. Melioidosis of the head and neck. Med J Malaysia 2001;56:471-7.  Back to cited text no. 19
Ganesan D, Puthucheary SD, Waran V. Melioidosis presenting as spinal epidural abscess. Br J Neurosurg 2003;17:568-71.  Back to cited text no. 20
Pit S, Chea FK, Jamal F. Melioidosis with brain abscess. Postgrad Med J 1988;64:140-2.  Back to cited text no. 21
Woods ML, Currie BJ, Howard DM, Tierney A, Watson A, Anstey NM, et al. Neurological melioidosis: Seven cases from the Northern Territory of Australia. Clin Infect Dis Off Publ Infect Dis Soc Am 1992;15:163-9.  Back to cited text no. 22
Currie BJ, Fisher DA, Howard DM, Burrow JN. Neurological melioidosis. Acta Trop 2000;74:145-51.  Back to cited text no. 23
Vidyalakshmi K, Lipika S, Vishal S, Damodar S, Chakrapani M. Emerging clinico-epidemiological trends in melioidosis: Analysis of 95 cases from western coastal India. Int J Infect Dis 2012;16:e491-497.  Back to cited text no. 24
Low JGH, Quek AML, Sin YK, Ang BSP. Mycotic aneurysm due to Burkholderia pseudomallei infection: Case reports and literature review. Clin Infect Dis Off Publ Infect Dis Soc Am. 2005;40:193-8.  Back to cited text no. 25
Lener S, Hartmann S, Barbagallo GMV, Certo F, Thomé C, Tschugg A. Management of spinal infection: A review of the literature. Acta Neurochir (Wien) 2018;160:487-96.  Back to cited text no. 26
Morse LP, Smith J, Mehta J, Ward L, Cheng AC, Currie BJ. Osteomyelitis and septic arthritis from infection with Burkholderia pseudomallei: A 20-year prospective melioidosis study from northern Australia. J Orthop 2013;10:86-91.  Back to cited text no. 27
Yee KC, Lee MK, Chua CT, Puthucheary SD. Melioidosis, the great mimicker: A report of 10 cases from Malaysia. J Trop Med Hyg 1988;91:249-54.  Back to cited text no. 28
Babinchak TJ, Riley DK, Rotheram, Jr. EB. Pyogenic vertebral osteomyelitis of the posterior elements. Clin Infect Dis 1997;25:221-4.  Back to cited text no. 29
Corrah TW, Enoch DA, Aliyu SH, Lever AM. Bacteraemia and subsequent vertebral osteomyelitis: A retrospective review of 125 patients. QJM Int J Med 2011;104:201-7.  Back to cited text no. 30
Kehrer M, Pedersen C, Jensen TG, Lassen AT. Increasing incidence of pyogenic spondylodiscitis: A 14-year population-based study. J Infect 2014;68:313-20.  Back to cited text no. 31
Nickerson EK, Sinha R. Vertebral osteomyelitis in adults: An update. Br Med Bull 2016;117:121-38.  Back to cited text no. 32
Pande A. Tuberculous Spondylitis. In: Thamburaj V, editor. Textbook of Contemporary Neurosurgery. 1 edition. Jaypee Brothers Medical Pub; 2012. p. 1445-54.  Back to cited text no. 33
Butler JS, Shelly MJ, Timlin M, Powderly WG, O'Byrne JM. Nontuberculous pyogenic spinal infection in adults: A 12-year experience from a tertiary referral center. Spine 2006;31:2695-700.  Back to cited text no. 34
Turunc T, Demiroglu YZ, Uncu H, Colakoglu S, Arslan H. A comparative analysis of tuberculous, brucellar and pyogenic spontaneous spondylodiscitis patients. J Infect 2007;55:158-63.  Back to cited text no. 35
Pande A. Fungal Infections. In: Tandon P, Ramamurthi R, editors. Ramamurthi and Tandon's Textbook of Neurosurgery. 3rd ed. Jaypee Brothers Medical Publications; 2012 pp 815-829.  Back to cited text no. 36
Tandon P, Pande A. Tuberculosis of the central nervous system. In: Tandon P, Tandon P, editors. Ramamurthi and Tandon's Textbook of Neurosurgery. Third edition. New Delhi: Jaypee Brothers Medical Publications; 2012 pp 725-41.  Back to cited text no. 37
Angsuwat M, Kavar B, Lowe AJ. Early detection of spinal sepsis. J Clin Neurosci 2010 Jan; 17:59-63.  Back to cited text no. 38
Azali HYA, Norly S, Wong LM, Tan KS, Safian NM. Liver abscess caused by tuberculosis and melioidosis. Asian J Surg 2007;30:138-40.  Back to cited text no. 39
Hin HS, Ramalingam R, Chunn KY, Ahmad N, Ab JR, Mohamed MS. Fatal co-infection-melioidosis and leptospirosis. Am J Trop Med Hyg 2012;87:737-40.  Back to cited text no. 40
Sulaiman H, Ponnampalavanar S, Mun KS, Italiano CM. Cervical abscesses due to co-infection with Burkholderia pseudomallei, Salmonella enterica serovar Stanley and Mycobacterium tuberculosisin a patient with diabetes mellitus. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24209898. [Last cited on 2018 May 15].  Back to cited text no. 41
Jeong D-K, Lee H-W, Kwon Y-M. Clinical value of procalcitonin in patients with spinal infection. J Korean Neurosurg Soc 2015;58:271-5.  Back to cited text no. 42
Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: A systematic review of clinical characteristics. Semin Arthritis Rheum. 2009;39:10-7.  Back to cited text no. 43
Modic MT, Feiglin DH, Piraino DW, Boumphrey F, Weinstein MA, Duchesneau PM, et al. Vertebral osteomyelitis: Assessment using MR. Radiology 1985;157:157-66.  Back to cited text no. 44
Ledermann HP, Schweitzer ME, Morrison WB, Carrino JA. MR imaging findings in spinal infections: Rules or myths? Radiology 2003;228:506-14.  Back to cited text no. 45
Mückley T, Schütz T, Kirschner M, Potulski M, Hofmann G, Bühren V. Psoas abscess: The spine as a primary source of infection. Spine 2003;28:E106-13.  Back to cited text no. 46
Navarro López V, Ramos JM, Meseguer V, Pérez Arellano JL, Serrano R, García Ordóñez MA, et al. Microbiology and outcome of iliopsoas abscess in 124 patients. Medicine (Baltimore) 2009;88:120-30.  Back to cited text no. 47
Shields D, Robinson P, Crowley TP. Iliopsoas abscess--a review and update on the literature. Int J Surg 2012;10:466-9.  Back to cited text no. 48
Euba G, Narváez JA, Nolla JM, Murillo O, Narváez J, Gómez-Vaquero C, et al. Long-term clinical and radiological magnetic resonance imaging outcome of abscess-associated spontaneous pyogenic vertebral osteomyelitis under conservative management. Semin Arthritis Rheum 2008;38:28-40.  Back to cited text no. 49
de Lucas EM, González Mandly A, Gutiérrez A, Pellón R, Martín-Cuesta L, Izquierdo J, et al. CT-guided fine-needle aspiration in vertebral osteomyelitis: True usefulness of a common practice. Clin Rheumatol 2009;28:315-20.  Back to cited text no. 50
Dinç H, Ahmetoǧlu A, Baykal S, Sari A, Sayil Ö, Gümele HR. Image-guided percutaneous drainage of tuberculous iliopsoas and spondylodiskitic abscesses: Midterm results. Radiology. 2002;225:353-8.  Back to cited text no. 51
Bernard L, Dinh A, Ghout I, Simo D, Zeller V, Issartel B, et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: An open-label, non-inferiority, randomised, controlled trial. Lancet 2015;385:875-82.  Back to cited text no. 52
Duarte RM, Vaccaro AR. Spinal infection: State of the art and management algorithm. Eur Spine J 2013;22:2787-99.  Back to cited text no. 53


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

This article has been cited by
1 Geographical distribution of Burkholderia pseudomallei in soil in Myanmar
Myo Maung Maung Swe, Mo Mo Win, Joshua Cohen, Aung Pyae Phyo, Htet Naing Lin, Kyaw Soe, Premjit Amorncha, Thin Thin Wah, Kyi Kyi Nyein Win, Clare Ling, Daniel M. Parker, David A. B. Dance, Elizabeth A. Ashley, Frank Smithuis, Alfredo G. Torres
PLOS Neglected Tropical Diseases. 2021; 15(5): e0009372
[Pubmed] | [DOI]
2 Neurological Melioidosis Presenting as Rhombencephalitis, Optic Neuritis, and Scalp Abscess with Meningitis: A Case Series from Southern India
Aparajita Chatterjee, Kavitha Saravu, Chiranjay Mukhopadhyay, Vijay Chandran
Neurology India. 2021; 69(2): 480
[Pubmed] | [DOI]
3 A review of imaging findings in melioidosis: revealing the tropics’ dirty secret
James Harvey, Bridget Boles, Dougal Brown
Radiology of Infectious Diseases. 2020; 7(4): 176
[Pubmed] | [DOI]


Print this article  Email this article
Online since 20th March '04
Published by Wolters Kluwer - Medknow