Rectourethral fistula as the presentation of disseminated urogenital meliodosisS Rajaian1, M Pragatheeswarane1, M Ramachandran2, P Narayanan3
1 Department of Urology, MIOT International, Chennai, Tamil Nadu, India
2 Department of Radiology, MIOT International, Chennai, Tamil Nadu, India
3 Department of Microbioloy, MIOT International, Chennai, Tamil Nadu, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.JPGM_86_21
Source of Support: None, Conflict of Interest: None
A 60-year-old male presented with diarrhea, fever, hiccoughs, and chills of 2 weeks duration. He developed acute urinary retention 6 days ago and was catheterized with 16 Fr Foley. His past history was significant for poorly controlled type II diabetes mellitus and old pulmonary tuberculosis (23 years ago). On examination, he was dehydrated, tachycardiac, and tachypnoeic. Digital rectal examination revealed grade 2 tender prostate with irregular nodularity in the anterior rectal wall with edematous rectal mucosa. The urethral catheter was draining well. Right testis and epididymis were grossly enlarged with edematous scrotal wall. His serum creatinine was 2.1 mg/dl and total leucocyte count was 24520 cells/mm3.
Urine ketones were negative. He was resuscitated and admitted in intensive care unit. Magnetic resonance imaging of abdomen and pelvis showed features of irregular multifocal acute prostatic abscesses with extension of the abscess through the rectal wall into the rectal lumen [[Figure 1], Panel a, b, c]. There was extracapsular extension of the abscess to the left side of pelvis lateral to the rectum. The features were suggestive of prostatic abscesses with periprostatic extension and rectourethral fistula. Color Doppler examination of the scrotum showed that right testis was completely replaced with pus pockets.
In view of multiple prostatic abscesses and testicular abscess with persistent features of sepsis, he was taken up for transurethral drainage of prostatic abscess with suprapubic cystostomy (SPC) and right orchidectomy [[Figure 1], Panel d]. Diversion sigmoid loop colostomy was also performed. About 15 mL of thick greenish yellow pus was drained. The pus was negative for tuberculosis and fungi. Gram staining revealed classical bipolar staining of Burkholderia psuedomallei and obligate aerobe growth on MacConkey Agar plate showed dry and wrinkled non-lactose fermenting colonies [[Figure 2], Panel a, b]. Blood cultures were negative. He was treated with intravenous ceftazidime 2 g given twice daily then with meropenem 1 g given thrice daily for 1 week according to culture sensitivity. Gradually his clinical condition improved. His renal parameters were normalized. He was discharged with SPC and diversion colostomy. Patient received eradication therapy with trimethoprim 320 mg/sulfamethaxazole 1600 mg and doxycycline 100 mg twice daily for 3 months. At 3-month follow-up, retrograde urethrogram and micturating cystourethrogram showed no communication between prostate and rectum [[Figure 3], Panel a, b]. There was also no contrast extravasation to prostate in computerized tomoraphy colonogram [[Figure 3], Panel c]. Subsequently patient underwent colostomy reversal followed by SPC removal. Patient was voiding well at 6-month follow-up.
Melioidosis is a bacterial infectious disease caused by Burkholderia pseudomallei. The disease primarily affects individuals with immunocompromised status and those in contact with soil and water. It carries a high mortality rate, about 10–50% even after treatment.,, The first human cases of meliodosis were reported in autopsy series by Whitmore and Krishnaswami at Rangoon in 1911. The risk factors are diabetes mellitus, alcohol overuse, chronic renal disease, chronic pulmonary disease, immunosuppression, and malignancy. In adults, pneumonia is the most frequent clinical manifestation, but prostatic abscess is also common, with 21% of male patients affected in a recent case series. Accordingly, many clinicians suggest that all men with systemic melioidosis should be screened for prostatic abscess as disease relapse is common without surgical drainage.,,
Meliodosis is endemic in India, Southeast Asia, and Australia. The most common presentation is acute illness accounting for about 85% of the cases. The mean incubation period of acute melioidosis is 9 days (range: 1–21 days). The clinical manifestation of the disease can range from simple skin changes to severe organ problems. Approximately, 20% of infected males develop prostatic abscess characterized by pain during urination, difficulty in passing urine, and urinary retention requiring catheterization. Rectal examination shows inflammation of the prostate. The presence of nonspecific signs and symptoms has caused melioidosis to be nicknamed “the great mimicker.”
Chronic melioidosis is usually defined by symptoms lasting longer than 2 months, and occurs in about 10% of patients. Clinical presentations include fever, weight loss, and productive cough with or without bloody sputum, which may mimic tuberculosis. In addition, long-standing abscesses at multiple body sites may also present. In latent infection, immunocompetent people can clear the infection without showing any symptoms, but less than 5% of all melioidosis cases have activation after a period of latency. Melioidosis should be considered in the differential diagnosis in diabetic men with urinary tract infection and should not be overlooked. Antibiotic therapy in treating systemic meliodosis can be categorized into intensive and eradication therapy. Intensive therapy usually comprises ceftazidime 2 g or in resistant cases meropenem 1 g given intravenously thrice daily upto 10 to 14 days. Eradication therapy consists of trimethoprim 320 mg/sulfamethaxazole 1600 mg or doxycycline 100 mg or amoxicillin 815 mg/clavulanic acid 125 mg given twice daily upto 3 to 6 months according to patients. Diagnosis of melioidosis should also be considered in prostatic abscess with rectal fistula in absence of malignancy for prompt management and early recovery.
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[Figure 1], [Figure 2], [Figure 3]