Melioidosis is a life-threatening disease caused by Burkholderia pseudomallei, an aerobic gram-negative soil dwelling organism in tropical & subtropical environment. It causes 3-5% of cerebral infections with higher mortality than other bacterial abscesses.  It is difficult to isolate the organism because of prolonged incubation period. Here we present a case where neuroradiological imaging played an important role in diagnosis and management.

A 15-year-old girl presented with fever, headache, vomiting x 2 weeks, swaying to the right x 4 days. On examination she had right eye nystagmus & right sided cerebellar signs. CSF analysis showed 180 cells, lymphocytic predominance, elevated protein (86 mg/dL) & normal glucose. Cultures, Gene-Xpert, PCR of CSF was negative for bacteria and fungus. Brain MRI (T2W) showed hyperintensities in right MCP and trigeminal root enhancement. She received IV ceftriaxone, acyclovir for 2 weeks and discharged. She returned 10-days later with paraparesis, sensory level at T6, bladder & bowel involvement,  brisk DTR. CSF showed 70 cells with lymphocyte predominance, elevated protein (113 mg/dl), normal glucose. Microbiological studies of CSF was negative & blood cultures were sterile. Repeat MRI brain (T2W) including spinal cord showed 'tunnel sign' which is hyperintensities tracking along corticospinal tract, and trigeminal root enhancement, cerebellar microabscess & diffuse hyperintensities extending upto cauda equina. Systemic screening for abscess were negative. Antibody titres to Burholderia pseudomallei was positive (1: 2500) by IHA. Patient received IV Meropenem for 6-weeks, oral Trimethoprim-Sulfamethoxazole for 6-months. At last visit she had good improvement in clinical status & neuroimaging.

The presentation of neuromelioidosis is  varied with cerebral abscess (ring lesions), myelitis, rhombencephalitis, cranial nerve palsy and mimics demyelination.  Any patient presenting with subacute meningoencephalitis, hemiparesis, cerebellar features, fever especially from endemic regions with neuroimaging features of tracking along corticospinal tract, trigeminal root & nucleus enhancement, with brainstem and cerebellar abscess-Burkholderia pseudomallei should be considered as the etiologic agent.