Disseminated melioidosis complicated by infective endocarditis necessitating aortic and mitral valve replacement: a case report

Disseminated melioidosis complicated by infective endocarditis necessitating aortic and mitral valve replacement: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Disseminated melioidosis complicated by infective endocarditis necessitating aortic and mitral valve replacement: a case report Stuart Drazich-Taylor, James Meng, James Moore, Sani Aliyu, Cairistine Grahame-Clark, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8038608/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background Melioidosis is caused by Burkholderia pseudomallei , a saprophytic, intracellular, Gram-negative bacteria commonly found in soil and stagnant water in endemic areas of South-East-Asia and Australia. Melioidosis can present acutely with pneumonia, bacteraemia or with chronic disseminated infection involving distant organs. It is typically managed with an intensive phase of intravenous antibiotics followed by a consolidation phase with oral antibiotics, with length determined by the site and burden of infection. Case presentation A 78-year-old white, British man presented with shortness of breath and fever 2 weeks after returning from Thailand. A SARS-CoV-2 lateral flow test was positive, and the patient was treated initially for community acquired pneumonia. The patient failed to respond to empirical therapy and had ongoing fevers with an oxygen requirement. Burkholderia pseudomallei was first isolated from blood cultures on day 7 of admission and subsequently on days 10 and 14. A pansystolic murmur was detected with a transoesophageal echocardiogram demonstrating severe mitral stenosis with mobile masses seen on both aortic and mitral valves and within the left atrium. Additionally, there was disseminated infection with culture positive cutaneous disease and prostatic abscesses. The patient was successfully treated with 12 weeks of ceftazidime and high dose co-trimoxazole, before stopping therapy due to desquamating rash. The patient underwent replacement of both aortic and mitral valves three months after initial presentation. Valve cultures were negative, and the patient has remained well with suppressed inflammatory markers upon follow up. Conclusions Infective endocarditis is a rare complication of melioidosis and is usually managed conservatively with antibiotics and without surgery. The patient had no specific risk factors for melioidosis such as diabetes or immunosuppression but noted sandstorms while in Thailand which may have led to aerosolisation and pulmonary infection. This is the first case to our knowledge, of native valve endocarditis in a patient with melioidosis requiring bivalvular replacement surgery. This case highlights the importance of recognising potential complications associated with cardiovascular manifestations of melioidosis. Melioidosis Infective endocarditis Aortic valve replacement Burkholderia pseudomallei Figures Figure 1 Figure 2 Figure 3 Background Melioidosis is an infection caused by the Gram-negative bacillus Burkholderia pseudomallei ( B. pseudomallei) . [ 1 ] It is a tropical infection with a predominance in South-East Asia and Northern Australia. [ 2 ] It can present as both acute and chronic infections, typically with respiratory involvement and often with a high mortality. [ 3 ] As a saprophytic organism found in soil and water, infection is associated with direct contact or aerosolisation. [ 4 ] The difficulty in diagnosing melioidosis is in its diversity of clinical presentations. [ 5 , 6 ] In endemic areas melioidosis commonly presents as pneumonia with bacteraemia. [ 1 ] Treatment is in accordance with the Darwin guidelines and involves a period of intravenous therapy followed by prolonged oral consolidation therapy. [ 7 ] We present the successful treatment of a 78-year-old Caucasian male who developed pneumonia, skin infection, prostatic abscesses and infective endocarditis following infection with B. pseudomallei. To our knowledge this is the first reported case of bivalvular native valve endocarditis caused by melioidosis necessitating aortic and mitral valve replacement surgery. Case Presentation A 78-year-old white, British, male with a background of ischaemic heart disease, hypertension and left ventricular hypertrophy presented to hospital with shortness of breath, dry cough and fevers after failing to improve with amoxicillin and clarithromycin in the community. He had recently returned from Thailand and had a positive lateral flow test for SARS-CoV-2 in the United Kingdom. On presentation his respiratory rate was 24 and oxygen saturations 97% on 2L. His heart rate was 80 and he had a temperature of 38.7 0 C. He was clammy and sweaty with coarse crepitations on the right side. His blood results showed WBC 9.0 x 10 9 /L, neutrophils 7.78 x 10 9 /L, lymphocytes 0.59 x 10 9 /L, CRP 291 mg/L and troponin 131.1 ng/L. ECG showed sinus rhythm with evidence of LV hypertrophy. A CXR on presentation showed cardiomegaly and right basal and midzone consolidation. He was treated as a community acquired pneumonia with type two myocardial infarction secondary to sepsis. He was given IV co-amoxiclav 1.2g 8-hourly and clarithromycin 500mg 12-hourly. On the respiratory ward, a pan systolic murmur was documented. A transthoracic echocardiogram showed calcified aortic valve and mobile heavily calcified mitral valve with severe stenosis. The patient was stepped down to oral co-amoxiclav and clarithromycin. On day 6 of admission the patient became febrile, and blood cultures were taken. A transoesophageal echo (TOE) showed aortic and mitral valve vegetations (Fig. 1 ). He was swapped to amoxicillin 2g four-hourly and gentamicin 1mg/kg twelve-hourly. On day 8 a blood culture revealed Gram-negative rods from the aerobic bottle. Oxidase positive colonies on chocolate agar were noted, direct disc sensitivities are visible in Table 1. VITEK 2 ID identified the organism as Burkholderia pseudomallei. He was changed to meropenem 2g IV 8-hourly. Table 1: Antimicrobial susceptibilities for Burkholderia pseudomallei performed in accordance with EUCAST recommendations Antibiotic Disc Diffusion (mm) MIC determined by gradient strip a (mg/L) MIC Interpretation Aztreonam 10 - - Cefuroxime 10 - - Cefpodoxime 13 - - Ceftazidime 26 2 Intermediate Chloramphenicol - 16 Resistant Ciprofloxacin 30 - - Co-amoxiclav 26 2 Intermediate Co-trimoxazole 44 0.125 Intermediate Doxycycline - 2 Intermediate Ertapenem 15 - - Gentamicin 6 - - Imipenem - 1 Sensitive Meropenem 30 2 Sensitive Piperacillin-tazobactam 34 - - a This testing method is not currently validated by EUCAST for determination of sensitivities for B. pseudomallei . At this point further travel history was elucidated. The patient had visited a beach resort in Phuket, Thailand for two weeks and had returned to the United Kingdom 13 days before admission. He visited a woodland area and fed an elephant but had washed his hands afterwards. The patient mentioned three sandstorms while on holiday. HIV testing was negative, and he was not diabetic . B. pseudomallei was cultured from repeat blood cultures on day 14 and from discharging lesions over the fourth and fifth left metacarpals. High dose cotrimoxazole 1920mg BD was added after the finding of prostate abscesses (Figure 2) on day 17. The prostate abscesses were drained three weeks into admission. Persistent hyponatraemia attributed to syndrome of inappropriate anti-diuretic hormone (SIADH), resolved upon fluid restriction and changing meropenem to ceftazidime 2g IV TDS. The patient responded biochemically (Figure 3) and completed a total of 12 weeks of antibiotics as an outpatient with ceftazidime and co-trimoxazole. Therapy was stopped due to desquamating rash. Bioprosthetic aortic and mitral valve replacement surgery was performed three months after the date of admission. Valve cultures were negative after prolonged incubation on Burkholderia cepacia agar. The patient recovered uneventfully from surgery and had a dual chamber pacemaker inserted 4 months after initial admission date. Discussion Our patient had disseminated melioidosis with respiratory, cardiac, cutaneous and prostatic involvement leading to a month-long admission and requirement for aortic and mitral valve replacement surgery. This patient had no specific risk factors for invasive melioidosis. It has been suggested that concurrent viral infections may lead to a more severe presentation of melioidosis [ 8 , 9 ]. It is possible that this patient’s recent SARS-CoV-2 led to increased susceptibility to melioidosis. Melioidosis predominates in northern Thailand, where it is a leading cause of bacteraemia, [ 10 ] although infections by B. pseudomallei are recognised in other regions including southern Thailand where the patient visited. [ 11 ] The patient likely acquired melioidosis from the inhalational route. Extreme weather events such as heavy rain and cyclones have been linked to melioidosis cases, [ 12 ] and in our patient, the coincidence of the rainy season with localised sandstorms may have led to infection. The patient presented with pneumonia. Septic deterioration and bacteraemia occurred after one week of admission, likely exacerbated by the de-escalation to oral antibiotics. He developed large vegetations and endocarditic masses within the left atrium. Endocarditis is a rare complication of melioidosis, reported in < 1% of cases. [ 2 , 13 , 14 ] A systemic review of cardiac involvement in melioidosis showed an equal distribution between aortic and mitral vegetations, albeit only in four patients. Of note, the lesions described therein were much smaller than our patient’s, did not describe intra-atrial involvement and none required surgery. Cases of prosthetic valve endocarditis caused by melioidosis have also been described, with a case in Colombia managed with aortic valve replacement and prolonged antibiotic therapy. [ 15 , 16 ] Conclusion In summary, we report a case of multi-system melioidosis complicated by infective endocarditis which was successfully treated with 12 weeks of combination antimicrobials and aortic and mitral valve replacement. Although rare, clinicians should be mindful of the potential for endocardial involvement with disseminated melioidosis and investigate and treat accordingly. Declarations Ethics approval and consent to participate Ethical approval was not needed for publication of this case report. The identity of the patient involved has been kept confidential. Consent for publication Written informed consent was obtained from the patient for publication of the manuscript and use of their images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests The authors declare no competing interests Funding None declared Author Contribution All authors were involved in the clinical care of the patient. SDT, James Moore, NE and SA led on the management of infection during the patient’s initial admission. CGC and James Meng were responsible for care of the patient from a cardiology perspective. RK and SP contributed to the management of infection as related to their cardiac surgery.SDT and James Meng prepared the initial manuscript. James Moore and CGC reviewed and annotated cardiac images. RK and SP provided information relating to the patient’s admission for cardiac surgery. All authors reviewed the final manuscript. Acknowledgements We would like to extend our thanks to the patient and their family for graciously allowing us to publish this case. Data Availability All relevant data is included within the completed manuscript. References Wiersinga WJ, Virk HS, Torres AG, Currie BJ, Peacock SJ, Dance DAB, et al. Melioidosis Nat Rev Dis Primer. 2018;4:17107. Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev. 2005;18:383–416. Gassiep I, Armstrong M, Norton R. Human melioidosis. Clin Microbiol Rev. 2020;33. Currie BJ. Melioidosis: evolving concepts in epidemiology, pathogenesis, and treatment. Semin Respir Crit Care Med. 2015;36:111–25. Saravu K, Mukhopadhyay C, Eshwara VK, Shastry BA, Ramamoorthy K, Krishna S, et al. Melioidosis presenting with mediastinal lymphadenopathy masquerading as malignancy: a case report. J Med Case Rep. 2012;6:1–4. Patil S, Gondhali G. Pulmonary melioidosis masquerading as tuberculosis: a case report. Electron J Gen Med. 2021;18. Sullivan RP, Marshall CS, Anstey NM, Ward L, Currie BJ. 2020 Review and revision of the 2015 Darwin melioidosis treatment guideline; paradigm drift not shift. PLoS Negl Trop Dis. 2020;14:e0008659. Norman FF, Blair BM, Chamorro-Tojeiro S, Gonzalez-Sanz M, Chen LH. The evolving global epidemiology of human melioidosis: a narrative review. Pathog Basel Switz. 2024;13. Gulati U, Nanduri AC, Juneja P, Kaufman D, Elrod MG, Kolton CB, et al. Case report: a fatal case of latent melioidosis activated by COVID-19. Am J Trop Med Hyg. 2022;106:1170–2. Kanoksil M, Jatapai A, Peacock SJ, Limmathurotsakul D. Epidemiology, microbiology and mortality associated with community-acquired bacteremia in northeast Thailand: a multicenter surveillance study. PLoS ONE. 2013;8:e54714. Hantrakun V, Kongyu S, Klaytong P, Rongsumlee S, Day NPJ, Peacock SJ, et al. Clinical epidemiology of 7126 melioidosis patients in thailand and the implications for a national notifiable diseases surveillance system. Open Forum Infect Dis. 2019;6:ofz498. Merritt AJ, Inglis TJJ. The role of climate in the epidemiology of melioidosis. Curr Trop Med Rep. 2017;4:185–91. Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis. 2010;4:e900. Velusamy R, Muhi S. Melioidosis and the heart: a systematic review. Trop Med Infect Dis. 2020;5. Pérez M, Currea M, Martı́nez C, Pérez J, Arango Á. Prosthetic valve endocarditis in melioidosis. Case report. Rev Chil Infectologı́a. 2021;38:816–9. Pownell C, Marsden BE, Lam W, Smith S, Hanson J. Prosthetic valve infective endocarditis due to Burkholderia pseudomallei: A case report and review of the literature. Acta Trop. 2024;261:107492. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Dec, 2025 Reviews received at journal 18 Dec, 2025 Reviews received at journal 09 Dec, 2025 Reviews received at journal 08 Dec, 2025 Reviews received at journal 08 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers invited by journal 02 Dec, 2025 Editor invited by journal 12 Nov, 2025 Editor assigned by journal 12 Nov, 2025 Submission checks completed at journal 12 Nov, 2025 First submitted to journal 05 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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B: Aortic valve long axis view with vegetation present on mitral valve. C: Three-chamber view with vegetations on aortic and mitral valves. D: Three-dimensional view of normal mitral valve compared to patient abnormal mitral valve with vegetation. A 1cm mobile mass was attached to the posterior mitral valve causing severe eccentric mitral regurgitation. The right coronary cusp of the aortic valve had a mobile mass measuring 0.84 cm x 0.54 cm. There were also endocarditic left atrial masses.\u003c/p\u003e","description":"","filename":"floatimage136.png","url":"https://assets-eu.researchsquare.com/files/rs-8038608/v1/e7f7cccb3a5ff7660641c6c4.png"},{"id":97674522,"identity":"507bdef0-3591-4e13-baa4-2d9e936cad69","added_by":"auto","created_at":"2025-12-08 09:43:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":351274,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProstate abscesses on MRI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure legend: A 5.5 x 4.8 x 4.2 cm abscess in the right transition zone of the prostate and a further 3.0 x 2.4 x 2.3 cm abscess within the left posterior peripheral zone.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8038608/v1/4256bf2eb1e1a19bb84a326e.png"},{"id":97654722,"identity":"556c9082-8f81-4536-94cb-ea976d28dbaa","added_by":"auto","created_at":"2025-12-08 07:02:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":180171,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTimeline of patient treatment\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8038608/v1/3c31859ac924faf646ab10ae.png"},{"id":97678863,"identity":"9783a35f-c692-44af-a114-983a90f783c5","added_by":"auto","created_at":"2025-12-08 09:56:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1736854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8038608/v1/d086136b-6731-44ff-948d-d59c146cdef3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disseminated melioidosis complicated by infective endocarditis necessitating aortic and mitral valve replacement: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eMelioidosis is an infection caused by the Gram-negative bacillus \u003cem\u003eBurkholderia pseudomallei\u003c/em\u003e (\u003cem\u003eB. pseudomallei)\u003c/em\u003e. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] It is a tropical infection with a predominance in South-East Asia and Northern Australia. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] It can present as both acute and chronic infections, typically with respiratory involvement and often with a high mortality. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] As a saprophytic organism found in soil and water, infection is associated with direct contact or aerosolisation. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe difficulty in diagnosing melioidosis is in its diversity of clinical presentations. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] In endemic areas melioidosis commonly presents as pneumonia with bacteraemia. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Treatment is in accordance with the Darwin guidelines and involves a period of intravenous therapy followed by prolonged oral consolidation therapy. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWe present the successful treatment of a 78-year-old Caucasian male who developed pneumonia, skin infection, prostatic abscesses and infective endocarditis following infection with \u003cem\u003eB. pseudomallei.\u003c/em\u003e To our knowledge this is the first reported case of bivalvular native valve endocarditis caused by melioidosis necessitating aortic and mitral valve replacement surgery.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 78-year-old white, British, male with a background of ischaemic heart disease, hypertension and left ventricular hypertrophy presented to hospital with shortness of breath, dry cough and fevers after failing to improve with amoxicillin and clarithromycin in the community. He had recently returned from Thailand and had a positive lateral flow test for SARS-CoV-2 in the United Kingdom. On presentation his respiratory rate was 24 and oxygen saturations 97% on 2L. His heart rate was 80 and he had a temperature of 38.7\u003csup\u003e0\u003c/sup\u003eC. He was clammy and sweaty with coarse crepitations on the right side.\u003c/p\u003e\u003cp\u003eHis blood results showed WBC 9.0 x 10\u003csup\u003e9\u003c/sup\u003e/L, neutrophils 7.78 x 10\u003csup\u003e9\u003c/sup\u003e/L, lymphocytes 0.59 x 10\u003csup\u003e9\u003c/sup\u003e/L, CRP 291 mg/L and troponin 131.1 ng/L. ECG showed sinus rhythm with evidence of LV hypertrophy. A CXR on presentation showed cardiomegaly and right basal and midzone consolidation. He was treated as a community acquired pneumonia with type two myocardial infarction secondary to sepsis. He was given IV co-amoxiclav 1.2g 8-hourly and clarithromycin 500mg 12-hourly. On the respiratory ward, a pan systolic murmur was documented. A transthoracic echocardiogram showed calcified aortic valve and mobile heavily calcified mitral valve with severe stenosis. The patient was stepped down to oral co-amoxiclav and clarithromycin.\u003c/p\u003e\u003cp\u003eOn day 6 of admission the patient became febrile, and blood cultures were taken. A transoesophageal echo (TOE) showed aortic and mitral valve vegetations (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). He was swapped to amoxicillin 2g four-hourly and gentamicin 1mg/kg twelve-hourly.\u003c/p\u003e\u003cp\u003eOn day 8 a blood culture revealed Gram-negative rods from the aerobic bottle. Oxidase positive colonies on chocolate agar were noted, direct disc sensitivities are visible in Table 1. VITEK 2 ID identified the organism as \u003cem\u003eBurkholderia pseudomallei.\u003c/em\u003e He was changed to meropenem 2g IV 8-hourly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eAntimicrobial susceptibilities for \u003cem\u003eBurkholderia pseudomallei\u0026nbsp;\u003c/em\u003eperformed in accordance with EUCAST recommendations\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAntibiotic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDisc Diffusion (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMIC determined by gradient strip\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMIC Interpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAztreonam\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCefuroxime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCefpodoxime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCeftazidime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eChloramphenicol\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eResistant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCiprofloxacin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCo-amoxiclav\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCo-trimoxazole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDoxycycline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eErtapenem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eGentamicin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eImipenem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSensitive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMeropenem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSensitive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePiperacillin-tazobactam\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eThis testing method is not currently validated by EUCAST for determination of sensitivities for \u003cem\u003eB. pseudomallei\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eAt this point further travel history was elucidated. The patient had visited a beach resort in Phuket, Thailand for two weeks and had returned to the United Kingdom 13 days before admission. He visited a woodland area and fed an elephant but had washed his hands afterwards. The patient mentioned three sandstorms while on holiday. HIV testing was negative, and he was not diabetic\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eB. pseudomallei\u0026nbsp;\u003c/em\u003ewas cultured from repeat blood cultures on day 14 and from discharging lesions over the fourth and fifth left metacarpals. High dose cotrimoxazole 1920mg BD was added after the finding of prostate abscesses (Figure 2) on day 17. The prostate abscesses were drained three weeks into admission. Persistent hyponatraemia attributed to syndrome of inappropriate anti-diuretic hormone (SIADH), resolved upon fluid restriction and changing meropenem to ceftazidime 2g IV TDS.\u003c/p\u003e\n\u003cp\u003eThe patient responded biochemically (Figure 3) and completed a total of 12 weeks of antibiotics as an outpatient with ceftazidime and co-trimoxazole. Therapy was stopped due to desquamating rash. Bioprosthetic aortic and mitral valve replacement surgery was performed three months after the date of admission. Valve cultures were negative after prolonged incubation on \u003cem\u003eBurkholderia cepacia\u003c/em\u003e agar. The patient recovered uneventfully from surgery and had a dual chamber pacemaker inserted 4 months after initial admission date.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur patient had disseminated melioidosis with respiratory, cardiac, cutaneous and prostatic involvement leading to a month-long admission and requirement for aortic and mitral valve replacement surgery. This patient had no specific risk factors for invasive melioidosis. It has been suggested that concurrent viral infections may lead to a more severe presentation of melioidosis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It is possible that this patient’s recent SARS-CoV-2 led to increased susceptibility to melioidosis.\u003c/p\u003e\u003cp\u003eMelioidosis predominates in northern Thailand, where it is a leading cause of bacteraemia, [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] although infections by \u003cem\u003eB. pseudomallei\u003c/em\u003e are recognised in other regions including southern Thailand where the patient visited. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The patient likely acquired melioidosis from the inhalational route. Extreme weather events such as heavy rain and cyclones have been linked to melioidosis cases, [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and in our patient, the coincidence of the rainy season with localised sandstorms may have led to infection.\u003c/p\u003e\u003cp\u003eThe patient presented with pneumonia. Septic deterioration and bacteraemia occurred after one week of admission, likely exacerbated by the de-escalation to oral antibiotics. He developed large vegetations and endocarditic masses within the left atrium. Endocarditis is a rare complication of melioidosis, reported in \u0026lt; 1% of cases. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] A systemic review of cardiac involvement in melioidosis showed an equal distribution between aortic and mitral vegetations, albeit only in four patients. Of note, the lesions described therein were much smaller than our patient’s, did not describe intra-atrial involvement and none required surgery. Cases of prosthetic valve endocarditis caused by melioidosis have also been described, with a case in Colombia managed with aortic valve replacement and prolonged antibiotic therapy. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, we report a case of multi-system melioidosis complicated by infective endocarditis which was successfully treated with 12 weeks of combination antimicrobials and aortic and mitral valve replacement. Although rare, clinicians should be mindful of the potential for endocardial involvement with disseminated melioidosis and investigate and treat accordingly.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eEthical approval was not needed for publication of this case report. The identity of the patient involved has been kept confidential.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e Written informed consent was obtained from the patient for publication of the manuscript and use of their images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNone declared\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors were involved in the clinical care of the patient. SDT, James Moore, NE and SA led on the management of infection during the patient’s initial admission. CGC and James Meng were responsible for care of the patient from a cardiology perspective. RK and SP contributed to the management of infection as related to their cardiac surgery.SDT and James Meng prepared the initial manuscript. James Moore and CGC reviewed and annotated cardiac images. RK and SP provided information relating to the patient’s admission for cardiac surgery. All authors reviewed the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe would like to extend our thanks to the patient and their family for graciously allowing us to publish this case.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll relevant data is included within the completed manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWiersinga WJ, Virk HS, Torres AG, Currie BJ, Peacock SJ, Dance DAB, et al. Melioidosis Nat Rev Dis Primer. 2018;4:17107.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev. 2005;18:383\u0026ndash;416.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGassiep I, Armstrong M, Norton R. Human melioidosis. Clin Microbiol Rev. 2020;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCurrie BJ. Melioidosis: evolving concepts in epidemiology, pathogenesis, and treatment. Semin Respir Crit Care Med. 2015;36:111\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaravu K, Mukhopadhyay C, Eshwara VK, Shastry BA, Ramamoorthy K, Krishna S, et al. Melioidosis presenting with mediastinal lymphadenopathy masquerading as malignancy: a case report. J Med Case Rep. 2012;6:1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatil S, Gondhali G. Pulmonary melioidosis masquerading as tuberculosis: a case report. Electron J Gen Med. 2021;18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSullivan RP, Marshall CS, Anstey NM, Ward L, Currie BJ. 2020 Review and revision of the 2015 Darwin melioidosis treatment guideline; paradigm drift not shift. PLoS Negl Trop Dis. 2020;14:e0008659.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNorman FF, Blair BM, Chamorro-Tojeiro S, Gonzalez-Sanz M, Chen LH. The evolving global epidemiology of human melioidosis: a narrative review. Pathog Basel Switz. 2024;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGulati U, Nanduri AC, Juneja P, Kaufman D, Elrod MG, Kolton CB, et al. Case report: a fatal case of latent melioidosis activated by COVID-19. Am J Trop Med Hyg. 2022;106:1170\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKanoksil M, Jatapai A, Peacock SJ, Limmathurotsakul D. Epidemiology, microbiology and mortality associated with community-acquired bacteremia in northeast Thailand: a multicenter surveillance study. PLoS ONE. 2013;8:e54714.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHantrakun V, Kongyu S, Klaytong P, Rongsumlee S, Day NPJ, Peacock SJ, et al. Clinical epidemiology of 7126 melioidosis patients in thailand and the implications for a national notifiable diseases surveillance system. Open Forum Infect Dis. 2019;6:ofz498.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMerritt AJ, Inglis TJJ. The role of climate in the epidemiology of melioidosis. Curr Trop Med Rep. 2017;4:185\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCurrie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis. 2010;4:e900.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVelusamy R, Muhi S. Melioidosis and the heart: a systematic review. Trop Med Infect Dis. 2020;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eP\u0026eacute;rez M, Currea M, Martı́nez C, P\u0026eacute;rez J, Arango \u0026Aacute;. Prosthetic valve endocarditis in melioidosis. Case report. Rev Chil Infectologı́a. 2021;38:816\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePownell C, Marsden BE, Lam W, Smith S, Hanson J. Prosthetic valve infective endocarditis due to Burkholderia pseudomallei: A case report and review of the literature. Acta Trop. 2024;261:107492.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Melioidosis, Infective endocarditis, Aortic valve replacement, Burkholderia pseudomallei","lastPublishedDoi":"10.21203/rs.3.rs-8038608/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8038608/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMelioidosis is caused by \u003cem\u003eBurkholderia pseudomallei\u003c/em\u003e, a saprophytic, intracellular, Gram-negative bacteria commonly found in soil and stagnant water in endemic areas of South-East-Asia and Australia. Melioidosis can present acutely with pneumonia, bacteraemia or with chronic disseminated infection involving distant organs. It is typically managed with an intensive phase of intravenous antibiotics followed by a consolidation phase with oral antibiotics, with length determined by the site and burden of infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 78-year-old white, British man presented with shortness of breath and fever 2 weeks after returning from Thailand. A SARS-CoV-2 lateral flow test was positive, and the patient was treated initially for community acquired pneumonia. The patient failed to respond to empirical therapy and had ongoing fevers with an oxygen requirement. \u003cem\u003eBurkholderia pseudomallei\u003c/em\u003ewas first isolated from blood cultures on day 7 of admission and subsequently on days 10 and 14.\u003c/p\u003e\n\u003cp\u003eA pansystolic murmur was detected with a transoesophageal echocardiogram demonstrating severe mitral stenosis with mobile masses seen on both aortic and mitral valves and within the left atrium. Additionally, there was disseminated infection with culture positive cutaneous disease and prostatic abscesses.\u003c/p\u003e\n\u003cp\u003eThe patient was successfully treated with 12 weeks of ceftazidime and high dose co-trimoxazole, before stopping therapy due to desquamating rash. The patient underwent replacement of both aortic and mitral valves three months after initial presentation. Valve cultures were negative, and the patient has remained well with suppressed inflammatory markers upon follow up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfective endocarditis is a rare complication of melioidosis and is usually managed conservatively with antibiotics and without surgery. The patient had no specific risk factors for melioidosis such as diabetes or immunosuppression but noted sandstorms while in Thailand which may have led to aerosolisation and pulmonary infection. This is the first case to our knowledge, of native valve endocarditis in a patient with melioidosis requiring bivalvular replacement surgery. This case highlights the importance of recognising potential complications associated with cardiovascular manifestations of melioidosis.\u003c/p\u003e","manuscriptTitle":"Disseminated melioidosis complicated by infective endocarditis necessitating aortic and mitral valve replacement: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 07:01:58","doi":"10.21203/rs.3.rs-8038608/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-22T07:34:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-18T13:42:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-10T02:22:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-09T02:49:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T12:09:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281848542232185800295610863720830345816","date":"2025-12-03T12:58:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88491221240539645386716994001788898131","date":"2025-12-03T07:44:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118143827000991100442467797922881672593","date":"2025-12-03T07:25:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189017731474738934387211585287547779295","date":"2025-12-02T23:50:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126392959817238806893492467351168350338","date":"2025-12-02T22:14:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-02T18:03:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-13T04:57:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-12T07:24:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-12T07:24:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-11-05T12:48:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b6c4107-7caf-4e97-9332-19f0b0105a5a","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-07T07:24:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 07:01:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8038608","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8038608","identity":"rs-8038608","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}