melioidosis , an infectious disease caused by burkholderia pseudomallei , has been reported sporadically from various parts of india . we report a case of septicemic melioidosis in a renal transplant recipient presenting with pneumonia , mediastinal lymphadenopathy , and graft dysfunction . he had 4/6 human leukocyte antigen match , negative cross match and received no induction . he received triple - drug immunosuppression with tacrolimus ( trough level 9.1 ng / ml at the fifth posttransplant month ) , azathioprine 2 mg / kg / day , and prednisolone 10 mg / day . he manifested gastrointestinal intolerance to both mycophenolate and enteric coated mycophenolic acid , and hence azathioprine was chosen . he had completed vaccination against hepatitis b , pneumococcus , and varicella - zoster prior to transplant . his allograft functioned normally ( serum creatinine 1.2 mg / dl ) until the fifth posttransplant month when he presented with continuous high - grade fever with chills and rigor and dry cough of 6 days duration . computerized tomography of chest [ figures 2 and 3 ] revealed subpleural nodules in the right upper lobe , some of them showing cavitation and extensive mediastinal lymphadenopathy involving para- and pre - tracheal , carinal , and bilateral hilar nodes [ figure 4 ] . the lymph node aspirate and bronchoalveolar lavage sample did not yield any specific organism upon staining and culture . arrow points to a cavitating nodule computed tomography thorax revealing extensive mediastinal lymphadenopathy he was given empiric antimicrobial coverage for community - acquired pneumonia with intravenous ceftriaxone and oral levofloxacin . he continued to have fever and was prescribed new regimens which included piperacillin tazobactam , meropenem , and vancomycin . azathioprine was stopped , and tacrolimus dose reduced to maintain a trough level of 7.2 ng / ml . he was resuscitated , and allograft biopsy was performed which revealed acute tubular injury . by the 4 week of illness , he began to expectorate sputum the culture of which grew b. pseudomallei . since he was allergic to cotrimoxazole , he was treated with oral doxycycline for eradication therapy . he remained afebrile at the end of three months of eradication therapy with good allograft function ( serum creatinine 1.3 mg / dl ) . this patient presented with high - grade continuous fever with chills and rigor , pneumonia with cavitating nodules , and extensive mediastinal lymphadenopathy . initial considerations included reactivation tuberculosis ( in lieu of past tuberculous pleural effusion ) with dissemination , fungal infections such as aspergillosis , cryptococcosis , and bacterial infections such as staphylococcal pneumonia which could cavitate . although posttransplant lymphoproliferative disorder ( ptld ) was a diagnostic possibility based on the findings of imaging studies , acute presentation with high grade continuous fever and progression to sepsis made ptld unlikely . staphylococcal pneumonia presents with thin - walled cavities distended with air ( pneumatoceles ) while the patient had thick walled cavities . blood culture grew none and sputum culture done in the 4 week of illness isolated b. pseudomallei . there is a paucity of information regarding the magnitude of this infection in the different regions of india . the causative agent b. pseudomallei , a gram - negative aerobic bacillus , is a saprophyte found in the soil and surface water . it is a facultative intracellular organism transmitted by inhalation , ingestion , and cutaneous inoculation . melioidosis in transplant recipients could be due to primary infection or reactivation of latent infection . acute melioidosis pneumonia has a spectrum ranging from fulminant septic shock with high mortality to mild pneumonia with little mortality . on chest radiographs , diabetes mellitus , alcoholism , renal failure , and steroid therapy predispose to severe forms of melioidosis such as septicemic and pneumonic forms . diagnosis is based on isolation in culture or by serological investigations such as indirect hemagglutination , or enzyme - linked immunosorbent assay . b. pseudomallei readily grows in commercial culture media but could be mistaken for pseudomonas species . polymerase chain reaction assay of buffy coat could be used to detect this organism in febrile patients . treatment recommendation for adults consists of initial intensive therapy for at least 14 days with any one of intravenous ceftazidime , meropenem , or imipenem followed by eradication therapy for minimum of three months with cotrimoxazole or doxycycline . it may take a prolonged period of fever defervescence ( mean 12 days in a south indian study ) , and hence antibiotics need not be transitioned prematurely . the patient in this report had documented hypersensitivity to cotrimoxazole which precluded routine prophylaxis with the drug . whether cotrimoxazole prophylaxis could prevent melioidosis in transplant recipients needs to be answered . even though empiric regimen included meropenem , to which he might have responded , he was prematurely transitioned to another antibiotic . after a diagnosis of melioidosis , transplant recipients are prone to develop life - threatening forms of melioidosis such as pneumonic and septicemic forms . prompt consideration of this infection in transplant recipients in endemic regions in the setting of fever , pneumonia , lymphadenopathy , visceral abscess , and sepsis could facilitate early diagnosis , institution of specific antimicrobial therapy , and fasten recovery . since it may take a long time for defervescence of fever even with appropriate antimicrobial therapy , establishing a diagnosis of melioidosis will help to avoid premature withdrawal of effective antimicrobial drugs .
melioidosis , an infectious disease caused by burkholderia pseudomallei , is endemic in the northern australia and south - east asia . 
 it is an emerging disease in the indian subcontinent . 
 melioidosis tends to run a potentially lethal course in immunocompromised individuals and data in renal transplantation are scarce . 
 the clinical presentation of melioidosis is diverse , mimicking several other infectious diseases . 
 diagnosis could be delayed in transplant recipients . 
 choice and duration of antimicrobial therapy , management of immunosuppression , and patient and graft outcomes are other issues to be addressed . 
 we report septicemic melioidosis with pulmonary involvement in a 32-year old renal transplant recipient that caused acute allograft dysfunction .