20% of all community - acquired cases of septicaemia are caused by b. pseudomallei , with 40% mortality . a striking rise in cases of melioidosis was observed after the december 2004 tsunami , and the disease was also more common after floods in malaysia in 2015 ( http://www.promedmail.org/direct.php?id=3218685 ) . an augmentation of imported cases in western countries may be strongly correlated with increased international travel ( http://mkt.unwto.org/barometer ) . early diagnosis of melioidosis is important considering the high mortality observed without adequate antibiotic therapy . because empirical antibiotic regimens for community - acquired pneumonia in nonendemic countries may not provide adequate treatment for melioidosis , , melioidosis was diagnosed in three french travellers in december 2013 as well as in april and august 2015 at hpital avicenne , bobigny , france . the first patient was admitted to the emergency department with a 3-week history of community - acquired pneumonia with treatment failure . two days after admission , marked acute respiratory distress and multiple organ failure occurred , leading to the patient 's transfer to the intensive care unit for respiratory assistance and extracorporeal circulation . concomitant with the aggravation one blood culture drawn at admission was positive gram - negative bacilli on gram stain . subculture yielded gram - negative , oxidase - positive bacilli which could not be identified using a biochemical test strip ( api20e ; biomrieux , marcy ltoile , france ) . using molecular biology ( partial sequencing of the 16s rrna gene ) , patient 2 was admitted shortly after his return from borneo . at this stage , he received no antibiotics . on day 3 of hospitalization , an aerobic blood culture drawn at admission yielded gram - negative bacilli . rapid identification using matrix - assisted desorption ionization time of flight mass spectrometry ( maldi - tof ms ; microflex lt ; bruker daltonics , leipzig , germany ) was performed directly on the pellet of the blood culture . within less than 1 hour , the analysis yielded burkholderia thailandensis with a log score value of 1.83 ( using the standard bruker v4.0 database ) . querying the security - relevant ( sr ) library , which includes bioterrorism agents ( bruker ) , revealed b. pseudomallei , with a log score value of > 2.0 . the identification was confirmed 5 days later by molecular biology ( targeting genes bpscu2 and orf11 
 ) . biochemical characterization antimicrobial susceptibility testing by disk diffusion revealed susceptibility to compounds used in conventional treatment but an abnormal sensitivity to aminoglycosides ( e.g. gentamicin ) ( table  2 ) . patient 3 was originally a native of cambodia ; she has resided in france for 30 years but frequently returns to her home country . as in patient 2 , the bacilli were identified within less than an hour with maldi - tof ms as b. pseudomallei , with a log score value > 2.0 using the sr library . underlying predisposing conditions such as diabetes mellitus have been widely described ( e.g. patient 3 ) . patients 1 and 2 had no evident risk factors , but in patient 1 , skin lesions related to a tattoo may have constituted a source of exposure . there was a difference in the clinical presentation of the cases : patient 1 had a history of more than 2 weeks of inappropriate therapy , which may have led to body - wide dissemination of the pathogen , possibly explaining the severity of the clinical evolution . culture reading may be facilitated by using selective media , e.g. ashdown medium , which is not widely used in nonendemic countries . rapid diagnostic tools are also available in endemic countries , based on immunofluorescence , monoclonal antibodies or latex agglutination . in nonendemic countries , difficulties in identification stem from the lack of familiarity with the cultural characteristics and the nonuse of effective and specific diagnostic facilities . above all , b.  pseudomallei is usually misidentified as a culture contaminant when standard identification techniques are used ( e.g. api20ne , automated vitek ) . moreover , many malaysian strains show quite unusual biochemical characteristics and susceptibility to gentamicin , which may be misleading . in the cases reported here , the microbiologic diagnosis was made in two ways . in the first case , identification of b.  pseudomallei by phenotypic and molecular approaches took at least 4 days after the blood culture turned positive . in the two other cases , identification with maldi - tof ms gave a result the same day the blood culture turned positive . maldi - tof ms has been shown to be an accurate and rapid procedure for identification of b.  pseudomallei if the appropriate database is used . because this pathogen is not represented in the main spectra bruker biotyper database , the response obtained with this database is b. thailandensis , with average log score values reflecting the closeness of the two species and shared peaks in their mass spectra . identification of burkholderia species at the genus level using the standard bruker database should alert the microbiologist and trigger further specific characterization . speed in the detection of b.  pseudomallei in blood cultures allowed us to set up effective antibiotic therapy and protective measures without delay for laboratory workers . indeed , precautions must be taken in manipulating this pathogen , as it is considered to be a bioterrorism agent . international travel increases the potential spread of infectious diseases , and the number of travellers to endemic areas will inexorably expand . nonendemic countries will have to face increasing rates of imported cases that must be diagnosed rapidly using efficient procedures . maldi - tof ms can be applied successfully to the identification of b.  pseudomallei if a suitable database is used .
melioidosis is an endemic disease in southeast asia and northern australia . 
 an increasing number of cases are being reported in nonendemic countries , making the diagnosis less obvious . 
 we discuss the identification of burkholderia pseudomallei using matrix - assisted desorption ionization 
 time of flight mass spectrometry on the occasion of recent cases of imported melioidosis in french travellers .