1. Melioidosis, caused by Burkholderia pseudomallei, is rarely diagnosed in the US, and patients with melioidosis usually report travel to melioidosis-endemic areas.

2. Recent melioidosis outbreak in the US was linked to an aromatherapy spray product.

Evidence Rating Level: 4 (Below Average)

Study Rundown: Melioidosis is caused by the bacterium Burkholderia pseudomallei, which naturally occurs in soil and water in tropical and subtropical regions. The bacterium is transmitted via inhalation, ingestion, or percutaneously. Melioidosis manifests with a wide clinical syndrome, including skin abscesses without fever, pneumonia, generalized sepsis, genitourinary infection, and encephalomyelitis. Moreover, it is very rare in the US, with only about 12 cases reported per year to the CDC, predominately associated with recent travel to melioidosis-endemic areas. However, there is a gap in knowledge as to understanding non-travel related transmission of melioidosis, and this study reports a cluster of 4 cases of melioidosis that occurred in the US over a few months that was found to be associated with aromatherapy spray from Better Homes and Gardens that had been imported from India to the United States. This study was limited by a small patient pool and the relative rarity of melioidosis infection in the US. Nevertheless, these study’s findings are significant, as they demonstrate that exposure to imported products from where melioidosis is endemic can be a cause of transmission, and thus patients with a compatible illness, even if they haven’t traveled to these endemic regions, should still be considered for closer assessment for melioidosis.

Click to read the study in NEJM

Relevant Reading: A Tricky Diagnosis

In-Depth [case reports]: This series of 4 case reports followed 4 patients in Georgia, Kansas, Minnesota, and Texas who reported to have isolates that matched an isolate of B. pseudomallei obtained from a bottle of aromatherapy room spray from Better Homes and Garden, labeled as a “highly fragranced essential oil” with lavender and chamomile scent, imported from India to the United States. All 4 patients did not have a history of travel to melioidosis-endemic areas but were exposed to the aromatherapy room spray. They were all hospitalized early in their clinical course, and two eventually had positive blood cultures that confirmed melioidosis pneumonia. One patient died quickly from disseminated melioidosis that was complicated with Covid-19 infection, one patient had progression to fatal septic shock, one patient had a prolonged ICU stay with ongoing neurologic recovery, and one patient survived despite the development of melioidosis-related septic arthritis and osteomyelitis. For future suspected cases, a culture of B. pseudomallei from any specimen is diagnostic for the disease. Additionally, it is suggested that patients with isolates identified by automated systems as burkholderia be reevaluated for possible infection with B. pseudomallei, as confirmatory testing should be performed. Overall, this study demonstrated that there is a risk of melioidosis associated with exposure to imported products from endemic areas. This finding suggests that patients who have acute respiratory or neurologic symptoms should be considered candidates for melioidosis if they do not respond to initial treatment.

Image: PD

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