¡¡¡¡The patient worked as a shopkeeper, with previous occupation at a sawmill when he was younger. He denied being involved in agricultural work or any previous history of eye trauma. He also denied intravenous drug abuse, contact with tuberculosis patients or sexual promiscuity.

¡¡¡¡On examination, his general condition was satisfactory and vital signs were stable. No signs of meningism were noted.  Cardiovascular and respiratory systems were normal. Liver enlargement was palpable, but nonª²tender.

¡¡¡¡Eye examination showed no perception to light and positive reverse afferent pupillary defect over the left eye was noted, signifying the optic nerve was compromised. The left eye was proptosed with severely injected and chemotic conjunctiva (Figure 2). There was pus discharged from a fistula at the lateral part of upper eyelid (Figure 3). Cornea was clear. Anterior chamber was deep and quiet. Movements of the left eye were restricted in all directions of gaze. Optic disc was pale with presence of choroidal folds at the macula. Intraocular pressure was normal. There were mild diabetic retinopathy changes on both eyes.
Full blood picture showed leukocytosis with predominant neutrophils. Chest xª²ray showed right upper lobe consolidation in accordance with previous lung infection. Mantoux test was negative and sputum was not producible for acidª²fast bacilli (AFB) tests. Liver function test was elevated but ultrasound of the abdomen did not reveal any liver abscess. Random blood sugar was high which was later controlled with insulin.

¡¡¡¡His condition showed remarkable improvement after high dose parenteral ceftazidime 2mg three times per day with oral coª²trimoxazole 650mg twice per day. Unfortunately, the left eye vision was not salvageable. For eradication therapy, he was planned to receive oral coª²trimoxazole for 6 months at which this patient had defaulted followª²up. However, he had showed no relapse for more than one year.

¡¡¡¡DISCUSSION

¡¡¡¡Melioidosis is caused by motile, oxidative positive, gram negative aerobic bacilli, Burkholderia pseudomallei, formerly known as Pseudomonas pseudomallei. It is endemic in Southeast Asia, Northern Australia, some parts of India and sporadic over the other parts of the world[1]. However, there were few articles on the incidence in Malaysia[2ª²4]. Most of the cases presented with pneumonia (ranges from 40% to 67%)[1ª²4]. The incidence of ocular involvement was very rare. One reported case from Malaysia was a patient who presented with orbital and parotid abscess with intracranial extension[5]. Another reported case was in 1996 from Singapore[6]. Both cases presented with orbital cellulitis in patients who had diabetis and they ended up with mortality. It is believed that many other cases were not reported or undiagnosed since it is a nonª²notifiable disease in Malaysia. In Singapore it has become a notifiable disease since 1996.

¡¡¡¡Mortality rate of melioidosis in Malaysia is high, 38% died within 24 hours of admission and 42.9% died after 72 hours of admission[3]. Diabetics were a susceptible group[1ª²4]. Most of the survivors responded with ceftazidime as a standard regime antibiotic. However, the recurrence rate is high even after 20 years. In our case, the patient¬ðs condition deteriorated after completion of  intravenous ceftazidime 1mg for 2 weeks. A repeat  CT  scan of brain and orbit showed worsening of left orbital abscess, with extension to the lefttemporal lobe. A prolonged course of high dose parenteral ceftazidime 2mg three times per day plus oral coª²trimoxazole 650mg twice per day were given for 2 months as acute phase treatment. The patient was planned for maintenance dose of oral coª²trimoxazole 650mg twice per day for 6 months. On our last followª²up, he did not show any signs of recurrence up to one year.

¡¡¡¡In our patient, the diagnosis of melioidosis was picked up by positive culture of the blood and swab from the fistula of upper eyelid. It was also supported by the presence of Immunoglobin G to the organism.

¡¡¡¡This case highlights a patient with melioidosis   presented with orbital abscess, which was a rare presentation of melioidosis. It was complicated with septicemia and cerebral abscess. There was  a need to prolong and increase the dose of susceptible antibiotics in a case of melioidosis with multiple involvement of soft tissue and brain with septicemia, to prevent life threatening and vision threatening conditions.

¡¡¡¡¡¾²Î¿¼ÎÄÏס¿

¡¡¡¡1 Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clin Mocrobiol Rev 2005;18(2):383ª²416

¡¡¡¡2 How SH, Ng KH, Jamalludin AR, Shah A, Rathor Y. Melioidosis in Pahang, Malaysia. Med J Malaysia 2005;60(5):606ª²613

¡¡¡¡3 Pagalavan L. Melioidosis: the Johor Bahru experience. Med J Malaysia 2005;60(5):599ª²605

¡¡¡¡4 Heng BH, Goh KT, Yap EH, Loh H, Yeo M. Epidemiological surveillance of melioidosis in Singapore. Ann Acad Med Singapore 1998;27:478ª²484

¡¡¡¡5 Mohd Fauzi AR,Humairah SC,Azarisman Shah MS,Tahir M.Meliodosis presenting as orbital and parotic abscess with intracranial extension. The International Medical Journal 2002;1(2):www.eª²imj.com

¡¡¡¡6 Wong PK,Ng PH.Melioidosis presenting with orbital cellulitis. Singapore Med J 1996;37(2):220ª²221

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