title: Non-Caseating Granulomatous Infective Spondylitis: Melioidotic Spondylitis.
abstract: METHODS
  Retrospective clinical analysis.
  
  
  OBJECTIVE
  To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis.
  
  
  BACKGROUND
  Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen,Burkholderia pseudomallei, has been labeled as a bio-terrorism agent.
  
  
  METHODS
  We performed a retrospective analysis of patients who were culture positive forB. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels.
  
  
  RESULTS
  Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence ofB. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up.
  
  
  CONCLUSIONS
  Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.
authors.affiliation: Spinal Disorders Surgery Unit, Department of Orthopaedics, Christian Medical College, Vellore, India.
authors.forename: Justin
authors.initials: J
authors.lastname: Arockiaraj
authors.affiliation: Infectious Diseases Unit, Department of Medicine, Christian Medical College, Vellore, India.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Karthik
authors.affiliation: Department of Pathology, Christian Medical College, Vellore, India.
authors.forename: Veena
authors.initials: V
authors.lastname: Jeyaraj
authors.affiliation: Spinal Disorders Surgery Unit, Department of Orthopaedics, Christian Medical College, Vellore, India.
authors.forename: Rohit
authors.initials: R
authors.lastname: Amritanand
authors.affiliation: Spinal Disorders Surgery Unit, Department of Orthopaedics, Christian Medical College, Vellore, India.
authors.forename: Venkatesh
authors.initials: V
authors.lastname: Krishnan
authors.affiliation: Spinal Disorders Surgery Unit, Department of Orthopaedics, Christian Medical College, Vellore, India.
authors.forename: Kenny Samuel
authors.initials: KS
authors.lastname: David
authors.affiliation: Spinal Disorders Surgery Unit, Department of Orthopaedics, Christian Medical College, Vellore, India.
authors.forename: Gabriel David
authors.initials: GD
authors.lastname: Sundararaj
keywords: Antibiotics; Burkholderia pseudomallei; Melioidosis; Non-caseating granuloma; Spondylitis; Tuberculosis