Sinonasal Melioidosis in a Returned Traveller Presenting with Nasal Cellulitis and Sinusitis

We illustrate a case involving a 51-year-old man who presented to a tertiary hospital with sepsis secondary to an abscess of the nasal vestibule and pustular eruptions of the nasal mucosa. Associated cellulitis extended across the face to the eye, and mucosal thickening of the sinuses was seen on computed tomography. The patient underwent incision and drainage and endoscopic sinus surgery. Blood cultures and swabs were positive for a gram-negative bacillus, Burkholderia pseudomallei. He had multiple risk factors including travel to an endemic area. The patient received extended antibiotic therapy in keeping with published national guidelines. Melioidosis is caused by Burkholderia pseudomallei, found in the soil in Northern Australia and Asia. It is transmitted via cutaneous or inhaled routes, leading to pneumonia, skin or soft tissue abscesses, and genitourinary infections. Risk factors include diabetes, chronic lung disease, and alcohol abuse. It can exist as a latent, active, or reactivated infection. A high mortality rate has been identified in patients with sepsis. Melioidosis is endemic in tropical Northern Australia and northeastern Thailand where it is the most common cause of severe community-acquired sepsis. There is one other report of melioidosis in the literature involving orbital cellulitis and sinusitis. 1. Melioidosis of the Nose 1.1. Case A 51-year-old Caucasian man presented to a tertiary hospital in Melbourne, Australia, with 7 days of headache, myalgia, fevers, and sweats. There was cellulitis affecting the right side face with purulent discharge from a tender right nostril. He had poorly controlled type 2 diabetes requiring insulin and chronic hepatitis B. He was a 25-pack-year smoker, drank >6 standard drinks of alcohol per day, and occasionally snorted cocaine. He also travelled multiple times to Vietnam and worked as a cabinet maker. He was septic (temperature 39°C, heart rate 110？bpm and blood pressure 90/70？mmHg) with cellulitis extending from the nose across the right cheek and up to the right eye, including a preseptal orbital cellulitis. Visual acuity and eye movements were normal. The right nasal vestibule was tender and swollen with purulent discharge originating from it and the nasal septum. Biochemistry revealed an elevated C-reactive protein of 222.7 ( ) and a normal white cell count of ( ), neutrophils ( ), and lymphocytes ( ). Computed tomography (CT) revealed right sinus mucosal thickening and preseptal tissue swelling overlying the right orbit extending over the zygoma and the nose, with no intracranial collection,