Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Best regards,
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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Case report
Year : 2008 | Month : December | Volume : 2 | Issue : 6 | Page : 1196 - 1199

Cellulitis With Multiple Abscesses In Leg Due To Burkholderia Pseudomallei Infection-A Case Report

SHETTY A K*, HEGDE A**, SHETTY I N***, GOMES L****

*M.D.(Microbiology),Dept.ofMicrobiology,FrMuller's Medical College,Mangalore-575002,Karnataka,(India).**M.S.(GeneralSurgery),Dept.ofSurgery,***M.D.(Internal Medicine),***Department of Medicine,****MSc.(MedicalMicrobiology),Dept.ofMicrobiology, A.J.Institute of Medical Sciences, Mangalore-575004,Karnataka,(India).

Correspondence Address :
Dr.Anup Kumar Shetty,Asst.Prof.Dept.of Microbiology,Fr.Muller's Medical College,Kankanady,Mangalore-575002, Karnataka,(India)Tel:91-0824-2238273, Fax:91-0824-2436352;Cell:9900405220. e.mail:dranupshetty@rediffmail.com

Abstract

Burkholderia pseudomallei is the causative agent of melioidosis. It is endemic in Southeast Asian countries and northern Australia. It was rarely encountered in India earlier. Recently, a few cases of melioidosis have been reported from several parts of southern coastal India. Burkholderia pseudomallei is a rare aetiology for cellulitis. We report a case of melioidosis presenting as cellulitis, with multiple abscesses on the leg in a diabetic patient. The causative agent was identified in time and the patient was treated for it’s infection. The patient recovered completely after completion of the antibiotic regimen. Melioidosis is an emerging infectious disease in India.

Keywords

Melioidosis, Burkholderia pseudomallei, cellulitis. Melioidosis, Burkholderia pseudomallei, cellulitis.

How to cite this article :

SHETTY A K,HEGDE A,SHETTY I N,GOMES L. CELLULITIS WITH MULTIPLE ABSCESSES IN LEG DUE TO BURKHOLDERIA PSEUDOMALLEI INFECTION-A CASE REPORT. Journal of Clinical and Diagnostic Research [serial online] 2008 December [cited: 2019 Oct 19 ]; 2:1196-1199. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1196-1199&id=375

Introduction
Melioidosis is a disease of humans and animals caused by Burkholderia pseudomallei (B.pseudomallei), previously called as Pseudomonas pseudomallei (2). It may manifest as an asymptomatic infection, localised skin ulcer or abscess, or chronic pneumonia mimicking tuberculosis and fulminant septic shock with abscess in multiple internal organs(1). B.pseudomallei is often mistaken for Pseudomonas species, and either treated as such or ignored as a contaminant (6). B.pseudomallei is widely distributed in soil and stagnant water of endemic areas (1),(13). Cellulitis is commonly caused by Group A Streptococci, Staphylococci and other bacteria, but rarely by B.pseudomallei(20). Melioidosis is endemic in Southeast Asia and northern Australia (1),(4),(8). Sporadic reports of melioidosis from various parts of south India and this part of coastal India are being seen, and there is a lack of awareness about this disease (13),(14). This is the first case of melioidosis reported in this part of the country, presenting as cellulitis with multiple abscesses in the leg. Melioidosis is now increasingly recognized, and is an emerging infectious disease in India (6).

Case Report

A 50 year old female housewife was admitted with swelling of left leg since ten days, and fever since a week. Swelling of the leg started since 2 weeks, it gradually increased and was associated with pain and redness in the area. There was no history of any trauma to the leg. Fever was continuous, high grade and present since a week prior to admission. She was a known type-2 non-insulin dependent diabetic and hypertensive, on irregular treatment. The patient had previously developed a small abscess on the sole of the right foot six months back, for which she was treated with basic antibiotics and the wound healed. The cause of abscess was not investigated. On examination, the patient had cellulitis with multiple abscesses on the ankle, calf and the popliteal fossa. The patient had a temperature of 1030F, pulse rate of 98/min, blood pressure -200/110 mm Hg, random blood sugar -479mg/dl, total blood count of 28,000/cu.mm., with predominant neutrophilia. Blood urea was 50mg/dl, Serum creatinine was 1.1 mg/dl and Haemoglobin was 8.2 mg/dl. Ultrasonongraphy study of the abdomen was normal.

The patient was started on piperacillin/tazobactam (PTZ) injection. Incision and drainage was done on the sixth day to drain the pus pockets. Culture of the pus sample was done, which grew Gram negative, non-fermenting bacteria. The isolate was identified as B.pseudomallei by standard biochemical tests (2). Antibiotic susceptibility testing was done and was interpreted as per Clinical Laboratory Standards Institute Guidelines(3). The isolate was sensitive to ceftazidime, cefotaxime, piperacillin, ciprofloxacin, meropenem, doxycycline, trimethoprim-sulphamethoxazole (TSX) and chloramphenicol, and was resistant to ampicillin, cephalexin, cefuroxime, gentamicin and amoxicillin/clavulanate. The blood culture did not yield growth of any bacteria. The patient remained febrile even after nine days of antibiotic therapy with piperacillin/tazobactam and pus continued discharging. A second sample of pus was cultured, and B.pseudomallei was re- isolated, with a similar antibiotic susceptibility pattern. After B.pseudomallei was identified, antibiotic therapy was changed to the recommended regimen of Ceftazidime and TSX (1). The patient became afebrile within 48 hours after changing the antibiotics. Discharge from the incision site stopped after a week and gradually the wound became healthy. Diabetes and hypertension were managed with insulin and antihypertensives, respectively. The haemoglobin level was corrected after blood transfusion. Secondary suturing was done to close the incision site. After suture removal, the patient was discharged and put on maintenance therapy with doxycycline and TSX for three months (1). The patient recovered completely after completion of the therapy.

Discussion

Cellulitis is rarely caused by B.pseudomallei. An Indian bacteriologist, C.S. Krishnaswami, discovered and described this bacterium in 1912 while working with his physician colleague, A Whitmore under the British army in Burma (6). Melioidosis is endemic in Southeast Asia and northern Australia, with the largest number of reports from Thailand (1),(6). This organism is found more commonly in cleared irrigated sites such as rice paddies and surface waters of endemic areas (1),(14). In Australia, B.pseudomallei has been found in clay soils at a depth of 25 to 45cms. and it has been proposed that the bacteria move to the surface with the rising water table during wet seasons (15). The majority of melioidosis cases reported, occurred in monsoonal wet seasons (8) , (13) , (14), which was observed in this case also. Melioidosis is increasingly recognized in southern India, and is an emerging infectious disease (1) , (4) , (6) , (8) ,(14). It has also been reported from this part of the country, which is a coastal area, predominantly with fields of rice-paddies and facing heavy monsoons (13) , (14). The cases so far reported here either had septicaemia, septic arthritis, pneumonia or abscesses in internal organs (14). One case of cellulitis of neck with septicemia was reported (13). No case of cellulitis of leg with multiple abscesses had been reported so far, and hence this is the first case. Most diseases are from recent infections, but those with latency and reactivation are described up to 29 years after exposure (1). Modes of transmission include inhalation, ingestion and inoculation from contaminated soil through abrasions or lesions (4),(10),(12). Localized infection can occur without obvious infected wound or evidence of trauma (14). Our patient also had no history of trauma or ulcer on the left leg, and probably might have acquired the infection through abrasions on the feet.

The major risk factors for melioidosis include diabetes mellitus, excess alcoholism and renal disease. Other risk factors include chronic lung disease, thalassaemia, malignancies, steroid therapy, iron overload and tuberculosis (1),(7) (12). Our patient had the risk factor of diabetes. Most of the cases reported earlier had one or more risk factors, with diabetes leading the list. However, the disease can occur even without risk factors (9). B.pseudomallei can grow easily by ordinary culture methods, but it is usually mistaken for Pseudomonas species[ 6]. Unless there is awareness among the clinicians and microbiologists, cases may be under-reported, and patient management may go in the wrong direction. B.pseudomallei is characteristically resistant to penicillin, ampicillin, first and second generation cephalosporins, gentamicin, tobramycin and streptomycin (1). The recommended antibiotic therapy for melioidosis includes an initial intensive therapy with Ceftazidime (50mg/kg, up to 2g),every 6 hours, or Meropenem (25mg/kg, up to 1 g) every 8 hours, or Imipenem (25mg/kg, up to 1 g) every 6 hours with or without TSX (8/40mg/kg, up to 320/1600mg),every 12 hours for a minimum period of 10-14 days, followed by eradication therapy with TSX (8/40mg/kg, up to 320/1600mg) every 12 hours with or without doxycycline (2mg/kg, up to 100mg),every 12 hours, for 3 months. Relapses are common when a single drug is used (1). In this patient, though PTZ was susceptible in vitro, the patient did not respond clinically and remained febrile even after nine days of antibiotics, draining of the abscess and controlling diabetes. Similar observations were made in some cases reported previously (11). Only after commencing the recommended therapy, did the patient become afebrile and the pus stopped discharging.

Conclusion

To conclude, melioidosis is an emerging infectious disease in India, and can cause infection at almost any site. Possibilities of infection are high in endemic areas facing heavy monsoons, and in patients with risk factors for the disease. An efficient laboratory diagnosis can identify the causative agent even when there is no clinical suspicion. Successful cure from the disease can be achieved by following the proper antibiotic regimen.

Abbreviations
TSX Trimethoprim-sulphamethoxazole
PTZ Piperacillin-tazobactam

Key Message

Cellulitis with multiple abscesses, Melioidosis due to Burkholderia pseudomallei.

References

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. Mandell GL, Bennett JE, Dolin RD. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 6th ed. Philadelphia (PA): Elsevier Churchill Livingstone; 2005: 2622-32.
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. Whitmore A, Krishnaswami CS. An account of the discovery of a hither-to undescribed infective disease among the population of Rangoon. Indian Med Gaz 1912; 47:262-7.
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. Anuradha K, Meena AK, Lakshmi V. Isolation of Burkholderia pseudomallei from a case of septicaemia-a case repor. Indian J Med Microbiol 2003; 21(2):129-32.
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. Suputtamongkol Y, Chaowagul W, Chetchotisakd P, Lertpatanasuwun N, Intaranongpai S, Ruchutrakool T, et al. Risk factors for melioidosis and bacteremic melioidosis. Clin Infect Dis 1999; 29:408-13.
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. Punyagupta S, Melioidosis: Review of 686 cases and presentation of a new clinical classification. In: Punyagupta S, Sirisanthana T, Stapatayavong B, eds: Melioidosis. Bangkok: Bangkok medical; 1989: 217-29.
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. Athan E, Allworth AM, Engler E, bastin E, Cheng AC. Melioidosis in Tsunami survivors. Emerg Infect Dis 2005 Oct; 11(10):1638-39.
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. Howe C, Sampath A, Spotnitz M. The Pseudomallei group: A review. J Infect Dis 1971; 124:598-606.
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. Barth AL, Silva FAA, Hoffmann A, Vieira MI, Zavascki AP, Ferreira AG et al. Cystic fibrosis patient with Burkholderia pseudomallei infection acquired in Brazil. J Clin Microbiol 2007 Dec; 45(12):4077-80.
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. Chen KJ, Sun MH, Hou CH, Sun CC, Chen TL. Burkholderia pseudomallei endolphthalmitis. J Clin Microbiol 2007 Dec; 45(12):4073-4.
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. Dias M, Antony B, Aithala S, Hanumanthappa B, Pinto H, Rekha B. Burkholderia pseudomallei septicaemia - A case report. Indian J Med Microbiol 2004; 22(4):266-8.
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. Vidyalakshmi K, Shrikala B, Bharathi B, Suchitra U. Melioidosis: An under-diagnosed entity in western coastal India: A clinico-microbiological analysis. Indian J Med Microbial 2008; 25(3):245-8.
15.
. Thomas AD, Forbes FJ, Parker M. Isolation of Pseudomonas pseudomallei from clay layers at defined depths. Am J Epidmiol. 1979; 110:515-21.

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