Neurological and Systemic Manifestations of Melioidosis: A Three-Case Series From Eastern India

Melioidosis, caused by Burkholderia pseudomallei, is an under-recognized infection in India that frequently mimics tuberculosis and pyogenic infections, leading to diagnostic delays. Neurological melioidosis is rare but associated with significant morbidity and mortality. We describe three culture-confirmed cases of melioidosis encountered over a three-month period at a tertiary care center in eastern India. This series is, to our knowledge, the first from eastern India to document a temporally clustered, culture-confirmed spectrum of melioidosis, ranging from systemic bacteremic to fulminant neurological disease, within a single center. A 58-year-old diabetic male presented with fever and gluteal swelling and was diagnosed with systemic melioidosis based on positive blood cultures. He received intravenous meropenem for 14 days, followed by oral trimethoprim-sulfamethoxazole for 12 weeks, in accordance with Darwin guideline recommendations, showing a good clinical response. A 60-year-old diabetic male presented with fever, headache, and seizures, with MRI revealing subdural and epidural collections along with a cortical lesion suggestive of neuromelioidosis. Cerebrospinal fluid (CSF) was obtained and demonstrated neutrophilic pleocytosis with elevated protein. CSF culture did not yield growth. Central nervous system (CNS) involvement is, therefore, designated as probable based on blood-culture confirmation and neuroimaging. He was discharged against medical advice before completing therapy. A 62-year-old dairy farmer developed fulminant meningoencephalitis following environmental exposure and toe trauma. CSF analysis revealed neutrophilic pleocytosis (150 cells/mm³), elevated protein (180 mg/dL), and low glucose (30 mg/dL), consistent with bacterial meningitis. CSF culture was sterile, and blood cultures confirmed B. pseudomallei, with CNS involvement classified as probable. He deteriorated despite treatment and was discharged while ventilated. These cases highlight the wide clinical spectrum of melioidosis, the diagnostic challenge posed by neurological involvement, and the importance of early blood culture testing. Radiological findings may closely resemble tuberculosis or pyogenic infections, and hyponatraemia with elevated inflammatory markers may provide supportive clues. Early diagnosis and adherence to prolonged antimicrobial therapy are critical to improving outcomes in this emerging endemic infection.