By Stan Deresinski, MD, FACP

Clinical Professor of Medicine, Stanford University

SYNOPSIS: Four cases of melioidosis in four states occurred and at least one was traced to a contaminated commercial aromatherapy product.

SOURCE: CDC Health Network. Source identified and case definition established: Multistate investigation of non-travel associated Burkholderia pseudomallei infections (melioidosis) in four patients: Georgia, Kansas, Minnesota, and Texas – 2021. https://emergency.cdc.gov/han/2021/han00456.asp?ACSTrackingID=USCDC_511-DM69519&ACSTrackingLabel=HAN%20454%20-%20General%20Public&deliveryName=USCDC_511-DM69519

Between March and late July 2021, cases of melioidosis were detected in Georgia, Kansas, Minnesota, and Texas. Two of the four people with the infections, including a child, died. The first case, which occurred in Kansas in March, was fatal, as was the fourth case, which was diagnosed post-mortem in Georgia in July. None of the patients had traveled outside the continental United States.

Genetic analysis indicated that the isolates of Burkholderia pseudomallei causing the infections appeared identical. Initially, large numbers of specimens recovered from several patient households were evaluated, but the source of the infection was not found. This led to a second investigation that included types of specimens not tested previously. Polymerase chain reaction (PCR) testing of a bottle of an aromatherapy product in the home of the July Georgia victim who died identified the presence of B. pseudomallei — a Tier 1 select agent. Genetic testing confirmed its relatedness to the clinical isolates.

COMMENTARY

The implicated aromatherapy product, Better Homes and Gardens Lavender and Chamomile Essential Oil Infused Aromatherapy Room Spray with Gemstones, was manufactured in India and sold by Walmart at 55 stores as well as online. A recall that includes five other scents of the spray has been issued for 3,900 bottles that had been sold.

There is nothing distinctive about the presentation of melioidosis, so the diagnosis requires laboratory confirmation. If suspected, the laboratory should be notified because of the risk of infection associated with exposure. Another important laboratory issue is the fact that laboratory testing using automated identification algorithms, such as VITEK-2 and MALDI-TOF, may fail to identify the organism correctly. In fact, the Texas case in the cluster reviewed here was misidentified as Burkholderia thailandensis by MALDI-TOF. The Centers for Disease Control and Prevention states: “Consider re-evaluating patients with isolates identified on automated systems as Burkholderia spp. (specifically B. cepacia and B. thailandensis), Chromobacterium violaceum, Ochrobactrum anthropi; and, possibly, Pseudomonas spp., Acinetobacter spp., and Aeromonas spp.”

Acquisition of melioidosis in the United States in the absence of foreign travel is very rare, but one case was reported recently in a 56-year-old woman in whom the infection was traced to her freshwater aquarium.1 

REFERENCE

  1. Dawson P, Duwell MM, Elrod MG, et al. Human melioidosis caused by novel transmission of Burkholderia pseudomallei from freshwater home aquarium, United States. Emerg Infect Dis 2021;27. doi: 10.3201/eid2712.211756. [Online ahead of print].