title: Cervical abscesses due to co-infection with Burkholderia pseudomallei, Salmonella enterica serovar Stanley and Mycobacterium tuberculosis in a patient with diabetes mellitus.
abstract: BACKGROUND
  Infections due to Mycobacterium tuberculosis, Burkholderia pseudomallei and non-typhoidal Salmonella cause significant morbidity and mortality throughout the world. These intracellular pathogens share some common predisposing factors and clinical features. Co-infection with two of these organisms has been reported previously but, to our knowledge, this is the first time that infection with all three has been reported in one person.
  
  
  METHODS
  In September 2010, a 58-year-old diabetic Malaysian male presented with fever and a fluctuant mass on the right side of his neck. B. pseudomallei was isolated from an aspirate of this lesion and there was radiological evidence of disseminated infection in the liver and spleen. The recurrence of clinical symptoms over ensuing months prompted further aspiration and biopsy of a cervical abscess and underlying lymph nodes. Salmonella enterica serovar Stanley and then M. tuberculosis were identified from these specimens by culture and molecular methods. The patient responded to targeted medical management of each of these infections.
  
  
  CONCLUSIONS
  In endemic settings, a high index of suspicion and adequate tissue sampling are imperative in identifying these pathogenic organisms. Diabetes was identified as a predisposing factor in this case while our understanding of other potential risk factors is evolving.
authors.affiliation: Division of Infectious Diseases, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia. Edenhelmi@gmail.com.
authors.forename: Helmi
authors.initials: H
authors.lastname: Sulaiman
authors.forename: Sasheela
authors.initials: S
authors.lastname: Ponnampalavanar
authors.forename: Kein Seong
authors.initials: KS
authors.lastname: Mun
authors.forename: Claire M
authors.initials: CM
authors.lastname: Italiano
mesh_terms: D000038:Abscess / Q000382:microbiology; D016957:Burkholderia pseudomallei / Q000302:isolation & purification; D060085:Coinfection / Q000382:microbiology; D048909:Diabetes Complications / Q000382:microbiology*; D006801:Humans; D008297:Male; D008554:Melioidosis / Q000382:microbiology*; D008875:Middle Aged; D009169:Mycobacterium tuberculosis; D009333:Neck / Q000382:microbiology / Q000473:pathology; D012480:Salmonella Infections / Q000382:microbiology*; D019779:Salmonella enterica / Q000302:isolation & purification; D014376:Tuberculosis / Q000382:microbiology*