A case of osteoarticular melioidosis misdiagnosed as extra-pulmonary tuberculosis from low endemicity region in North-western India

We report a rare case of melioidosis involving femur and knee in a 62-year old diabetic male patient from low endemic region (Kota, Rajasthan, India). He was previously misdiagnosed as case of extra-pulmonary tuberculosis (EPTB). Patient's occupation (house building contractor) involving damp and humid soil for construction and non-response to anti-tubercular treatment aroused suspicion of melioidosis. <i>Burkholderia pseudomallei</i> was isolated on culture of pus aspirated from the non-healing osteo-articular lesions and confirmed by real-time PCR targeting T3SS1 gene (Type-3 secretion system 1). Although melioidosis is classified as a tropical disease of wet and humid climate, rare autochthonous cases have also been reported from arid regions in India (Rajasthan, Gujarat and Punjab). We propose that there might be environmental presence of <i>B. pseudomallei</i> in otherwise arid regions, demonstrated in this case where construction sites involving old or new buildings with predominantly moist soil was the likely source of infection. Therefore, a high index of suspicion for melioidosis in non-endemic areas is essential for early detection and treatment of melioidosis.