title: A melioidosis patient presenting with brainstem signs in the emergency department.
abstract: BACKGROUND
  Neurological abnormalities in melioidosis are rare but may manifest as an acute stroke, and in the emergency department (ED), an inappropriate stroke treatment may threaten a patient's life.
  
  
  OBJECTIVE
  A case of cerebral melioidosis is reported in a patient presenting with brainstem signs to increase awareness of the uncommon presentations of melioidosis that may cause a delayed diagnosis in the ED.
  
  
  METHODS
  A 45-year-old man who worked as a construction worker, with diabetes mellitus and alcoholic liver cirrhosis, presented to the ED after a 10-day period of fever and cough. He was initially diagnosed and treated as a case of community-acquired pneumonia. However, a sudden change in consciousness with 6th and 7th cranial nerve palsy and flaccid paralysis were noted while he was in the ED, and acute brainstem stroke was suspected. Brain magnetic resonance imaging disclosed brainstem lesions, slightly hypointense on T1-weighted images and hyperintense on T2-weighted images. Blood and urine cultures subsequently yielded Burkholderia pseudomallei. Abdominal computed tomography revealed multiple small consolidated patches, ground-glass opacities, small nodules in the lower lungs bilaterally, and a pancreatic tail abscess. Systemic melioidosis with lung, pancreas, urogenic tract, and brainstem involvement was diagnosed. Three weeks after admission, the patient died from a sudden onset of apnea and asystole.
  
  
  CONCLUSIONS
  In light of this case, patients with identifiable risk factors, especially underlying diabetes, a history of positive soil contact, and those who lived in an endemic area or ever traveled to an endemic area, and who present themselves with fever and neurologic deficit or multi-organ involvement, should have melioidosis considered in the differential diagnosis.
authors.affiliation: Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Chia-Te
authors.initials: CT
authors.lastname: Kung
authors.forename: Chao-Jui
authors.initials: CJ
authors.lastname: Li
authors.forename: Sheung-Fat
authors.initials: SF
authors.lastname: Ko
authors.forename: Chen-Hsiang
authors.initials: CH
authors.lastname: Lee
mesh_terms: D001927:Brain Diseases / Q000175:diagnosis* / Q000382:microbiology; D020526:Brain Stem Infarctions / Q000175:diagnosis*; D016957:Burkholderia pseudomallei / Q000302:isolation & purification; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D017809:Fatal Outcome; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008554:Melioidosis / Q000175:diagnosis* / Q000382:microbiology; D008875:Middle Aged