Case report long segment myelitis secondary to neuro melioidosis

Neuro-melioidosis, comprising 4% of all cases of melioidosis carries a risk of high morbidity and mortality. We describe two Sri Lankan patients presenting with long segment myelitis secondary to melioidosis.

Case 1: 47-year-old male presented with right side hemiparesis which progressed rapidly to quadriparesis. Initial cerebro spinal fluid (CSF) analysis revealed protein 76 mg/dl and glucose 72 mg/dl but without a cellular reaction. MRI spine revealed long segment myelitis with contrast enhancement. The patient was treated with intravenous methyl prednisolone pulses (IV MPP) and plasma exchanges(PLEX) on suspicion of an immune mediated myelitis but without success. A repeat MRI revealed high signal changes in the brain stem and along the entire spinal cord with contrast enhancement. MRI brain after treatment with MPP/PLEX showed enhancing hyper intensities along the corticospinal tracts. The repeat CSF revealed protein 1187 mg/dl, glucose 78 mg/dl, lymphocytes 1600/mm3 and neutrophils 10,200/mm3. CSF culture has become positive for Burkholderia pseudomallei. Serum melioidosis antibody titre was 1: 320. He was started on IV meropenem with oral cotrimoxazole for 12 weeks followed by oral co trimoxazole. But he had poor clinical recovery. Case 2: 47-year-old female presented with bilateral lower limb weakness for 1-week duration. On examination, she had flaccid paraparesis with a sensory level at T11. Inflammatory markers were elevated. CSF analysis revealed protein 50 mg/dl with lymphocytes 172/mm3. MRI pan spine revealed a long segment myelitis. Serum melioidosis antibody titre was 1: 640. She was treated with IV meropenem for 8 weeks followed by oral co-trimoxazole with an excellent clinical and radiological response.

Numerous neurological manifestations have been described with melioidosis, however long segment myelitis with a positive CSF culture is not yet reported. These cases signify the importance of considering melioidosis as a differential in patients with long segment myelitis especially in endemic areas.