A 62-year-old Male with Dreadful Dysuria

This case has been inspired by events in the Torres Straits and details have been changed to ensure patient anonymity.

History

A 62-year-old Male trudged into the Emergency Department on a Friday night. There was a downpour of rain outside as the wind was whistling through the windows and doors. This weather came as no surprise to anyone – it was after all the wet season. He complained of dysuria, urinary frequency and hesitancy for over two months. There was no blood or pus in his urine, no bowel symptoms, no abdominal or flank pain and no fevers. He had visited his GP a few weeks ago who diagnosed a urinary tract infection and given him a course of Trimethoprim.  Urine cultures at that time grew sensitive E. Coli. But his symptoms never seemed to have resolved and in fact now were worse. “Just fix the problem doc!!” were his words.

His had diabetes (on metformin and gliclazide); hypertension (on ramipril) and hypercholesterolaemia (on a statin). He was a ex-smoker, non-drinker, not currently working and enjoyed gardening.

Clinical Findings

His observations were in normal limits.

Significant central adiposity observed.

Abdomen soft, non-tender. No flank tenderness.

Tender prostate on PR examination.

Urine dipstick ++ leucs, + glucose, + protein

 

What are your differential diagnosis?
How would you approach this patient?
The Case Continued…

He was given another course of oral Trimethoprim on the Friday night and encouraged to return to his GP early the following week who arranged an ultrasound. He was found to have a prostatic abscess which was confirmed on CT abdomen when he went down to Cairns. The abscess was drained and cultures grew Burkholderia pseudomallei. He was treated with oral co-trimoxazole for 20 weeks.

Pearls from the Torres

Melioid or Melioidosis is a communicable disease caused by the gram-negative bacterium Burkholderia pseudomallei. It’s an important differential to consider during the wet season and is found in tropical areas around the world, primarily South East Asia and Northern Australia. Melioid is transmitted via direct contact with contaminated soil or water (either through skin abrasions or inhalation). Those at risk include diabetics, alcoholic misusers and those on steroids; however we are seeing more cases of Melioid affecting fit and healthy people. Interestingly those that are HIV positive are not at an increased risk of developing Melioidosis.

Clinical presentation varies and although it most commonly causes as cavitatory pneumonia, it can also present as unilateral parotitis, prostatic abscess and septic shock. Advanced infections carry a mortality rate of 80%. Diagnosis is made from blood, sputum or pus culture. Treat unwell patients with IV meropenam during the acute illness and then step down to oral maintenance with co-trimoxazole or doxycycline for 12-24 weeks to minimise relapse (under the guidance of your local infectious disease team). If working in a tropical environment – encourage your patients to wear enclosed shoes and gloves if handling soil. 

When it’s wet: think of Melioid

When they’re really sick: think of Melioid

When you’re not quite sure: think of Melioid

Further Reading

https://nt.gov.au/wellbeing/health-conditions-treatments/bacterial/melioidosis

Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology and management. Clin Microb Rev. 2005;18( 2): 383– 416.

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( 11): e900.