Melioidosis is increasingly recognized in tropical regions. It causes various manifestations including neurological involvement with significant morbidity and mortality if untreated. This case is unusual because this patient had clinical and radiological features supportive of demyelination but with frequent relapses and no underlying cause for immunosuppression.

Case presentation

A 15-year-old girl presented with 4 episodes of varying focal neurological deficits over 6 months.

Her first episode was with sudden onset left hemiparesis, slurred speech, right sided 6^th and lower motor neuron 7^th cranial nerve palsies. CSF revealed protein 50 mg/dl and lymphocytes 45/mm³. CSF viral and fungal studies, TB PCR and cultures were negative. MRI brain showed multiple bilateral asymmetrical non-enhancing T2-hyperintense lesions with diffusion restriction. She was treated with IV methylprednisolone resulting in recovery without residual deficits.

Her second episode was with left leg weakness, a left sided 6^th and lower motor neuron 7^th cranial nerve palsy. Repeat CSF was normal. Repeat MRI showed spatial and temporal changes in the white matter of both cerebral hemispheres with new lesions in the corpus callosum and conus medullaris, suggestive of demyelinating plaques. IV steroids and plasmapheresis resulted in complete recovery.

3 months later, she developed right hand weakness and numbness. After IV steroid treatment, her  symptoms resolved.

1 month later, she developed status epilepticus, aphasia, left upper motor neuron facial nerve palsy, bilaterally reduced palatal movements, left arm weakness with generalized brisk reflexes. CSF revealed protein 50 mg/dl, neutrophils 40/mm³, lymphocytes 5/mm³ with normal glucose and negative culture. MRI brain showed multiple ring enhancing lesions. Serum Melioidosis antibody titer was 1:1280. She made a  good recovery with IV Meropenum and Trimethoprim-Sulphamethoxazole without recurrence.

This case highlights the importance of considering Melioidosis in patients with atypical neurological presentations in endemic regions for better clinical outcome.