Undetectable disease that kills in 24 hours if untreated is spooking India

Some time during the end of 2015 Dr Om Shrivastav a consultant on infectious diseases at Saifee Hospital Charni Road organised a seminar attended by nearly 75 doctors What set this discussion apart was that it debated a disease that although discovered one hundred years ago still goes largely undetected since it mimics symptoms of other diseases mdash tuberculosis pneumonia and septicemia Once the bacterium burkholderia pseudomallei which causes it enters the blood stream it can cause death within 24 to 48 hours if untreatedLate last year Dr Om Shrivastav a consultant on infectious diseases at Saifee Hospital helped organise a seminar on melioidosis in association with researchers from Thailandrsquos Mahidol University this was to increase awareness about the disease among city doctors PICSatej ShindeMelioidosis would have in fact not come up in public discussion had it not been for a paper published last week in the journal Nature Microbiology by a team of 11 researchers Titled Predicted global distribution of Burkholderia pseudomallei and Burden of Melioidosis it has suddenly put India on a list of highly endemic countriesDr Chiranjay Mukhopadhyay professor at the department of microbiology at Manipal Universityrsquos Kasturba Medical College Karnataka who also heads the Indian Melioidosis Research Forum says that it has been revealed that South Asia mdash India Bangladesh and Sri Lanka mdash contribute to about 44 per cent of the worldrsquos melioidosis cases Of this India has the highest burden he adds While until now it was believed to be a largely rural malaise doctors and researchers admit that urban Indians are at high risk too Soil soot or contaminated water that you are exposed to during extreme conditions such as flooding or waterlogging during the annual monsoon can expose you to b pseudomalleiWater is a carrier of the burkholderia pseudomallei bacterium that causes melioidosis Experts say wading through waterlogged areas like Mumbaikars often do in the monsoon can put you at high risk PICNIMESH DAVEThe mimicking bacteriaItrsquos the stuff that makes great headlines The bacterium burkholderia pseudomallei is known to be a shapeshifting one and the symptoms of a melioidosis infection masquerade as those of other illnesses making diagnosis bafflingA patient will come with high fever cough chills abscess in internal organs mdash especially the liver and prostrate mdash bone and joint ache and rigors which is a sudden feeling of cold with shivering accompanied by a rise in temperature often with copious sweating says Mukhopadhyay who witnessed his first case in 2005 when he moved from Lucknow to ManipalIn 2012 Dr Chiranjay Mukhopadhyay who also heads the Indian Melioidosis Research Forum organised a soil workshop conducted in association with researchers from Cambridge and Mahidol universities The first of its kind in India it was conducted in Udipi Karnataka to identify the presence of the burkholderia pseudomallei in the soil and saw 50 participantsPICCourtesy to Indian Melioidosis Research ForumWhat was once believed to be a disease restricted largely to Thailand Vietnam and northern Australia researchers say is proliferating in India but going largely underdiagnosed as no one is looking for itThe bacterium sits one foot below surface level and it is believed that soil along the coastal regions of India eastern and western central India Bihar Uttar Pradesh Madhya Pradesh South India and North East carries the bacterium Therefore aside from portions of Kashmir everywhere you go in India you can be exposed to melioidosisMukhopadhyay says that he diagnosed his first case within a month of moving to Manipal Now his team spots between 30 and 50 cases every year At Vellore head of microbiology at Christian Medical College amp Hospital Balaji Veeraraghavan estimates that India reports about 60 cases each year The two agree and Shrivastav concurs that the numbers barely constitute the tip of the icebergIn fact I myself tested positive for melioidosis a few years ago due to a chance test says Veeraraghavan Earlier that year he had suffered severe chills rigors and high grade fever I went to my hospitalrsquos clinic and was told that I probably had viral fever I was told to go home and wait for a few days As I was heading out I crossed an intern in the hallway who asked if I had undergone a blood test Chumma we decided to do a subculture Five milliliters of blood was taken from Veeraraghavan and cultured to check the presence of b pseudomallei The next morning the test returned positive He was in hospital for 10 daysB pseudomallei bacterium in gram stainGraph courtesy authors of Predicted Global Distribution Of Burkholderia MelioidosisVeeraraghavan admits pointedly that he got lucky For every hour after b pseudomallei enters the bloodstream and is not treated mortality increases by 7 per cent he says adding that he probably got infected in the laboratoryConstruction is the enemyWith farmers spending hours around soil without protective footwear their exposure to the bacteria from soil and water increases making them more susceptible to the diseaseBut that assumption argues Mukhopadhyay no longer holds true You can even catch it by inhaling the bacteria from the air carried through dust or even when walking barefoot in a garden mdash something that many people in India do as a ritual in the mornings I have seen a businessman a homemaker and even students all from urban areas test positiveA photo of Aarey Milk Colony shows motorists battling dust from debris Doctors say constant construction and digging of roads in Mumbai throws up the bacterium burkholderia pseudomallei in the atmosphere leaving us susceptible to melioidosis PicSameer MarkandeThe economic boom says Veeraraghavan is a contributing factor With constant digging and incessant construction in towns and metros soil is being loosened and the bacteria being carried in the airWhat the bacteria needs to take over the body is a suppressed immune system and this makes India a ticking time bomb given that we have an estimated 651 million diabetics 2015 figure A condition like diabetes predisposes you to melioidosis he adds Those with chronic kidney disease and used to excessive alcohol also fall in the high risk groupIn the above mentioned research paper the authors mdash who predict that there will be 165000 cases that will emerge in the 2015 figures from among the three billion people living in areas that support the bacterium and that of these 89000 would have succumbed to it mdash have said that even a highly urbanized country like Singapore has reported 550 melioidosis cases in the last 10 yearsProblem of detectionAccording to the World Health Organisationrsquos 2015 report India with 22 million cases had the largest number of TB patients in the world in 2014 We reported 23 per cent of the global totalOf this estimates Mukhopadhyay 10 to 15 per cent would be cases of melioidosis In fact 15 per cent of cases of pneumonia and septicemia would also be cases of melioidosis There are several reasons for skewed numbersThe first as the cityrsquos microbiologists will tell you is because the clinician has to consciously ask the laboratory to look for burkholderia pseudomallei mdash something that happens very rarelyWhen SUNDAY midday spoke to Dr Jayanthi Shastri head of the department of microbiology at Nair Hospital she said Typically a clinician has to suspect melioidosis Itrsquos only then that our team will look for itThe other reason is that even if there is suspicion of melioidosis proving it may be difficultWhen a patient comes with the identified symptoms the first step is to prescribe generic antibiotics Once a patient has taken these tests for burkholderia pseudomallei will come negative says Shrivastav As is the case with most lab tests not all patients will test positive all the time The microbiologist at the lab has to be told what is suspected so that he knows what to look for The melioidosis bug Shrivastav calls fastidious In up to 40 per cent of patients a lab test will yield nothing A machine is not 100 per cent correct all the time he says adding that the lack of a standardized test also goes against detectionCurrently there are four kinds of tests that can be used to detect the presence of burkholderia pseudomallei a polymerase chain reaction the EnzymeLinked Immunosorbent Assay ELISA technique indirect fluorescentantibody tests and the culture method While Xrays and other scans are also routinely conducted even when certain characteristics of melioidosis are present mdash such as a honeycomb abscess in the liver mdash they are not considered enough for a diagnosisThe amount of blood extracted from the patient is also significant says Shrivastav We need a substantial quantity of it to be able to give the microbiologist a fair chance at detecting the bacteria Five to 20 ml of blood allows only a 40 to 60 per cent chance of detection It climbs to 90 to 95 per cent with a 40 ml sampleIn the oneandahalf months since the seminar at Saifee Hospital Shrivastav has learnt to look out for melioidosis He has detected four cases since then While two were from cities outside Mumbai one was from Dubai and a fourth from the cityFinding a line of treatmentIn the absence of a vaccine it becomes even more important to ensure that medication reaches the patient on time While the average line of antibiotics may help stave off TB or another ailments the burkholderia pseudomallei is only suppressed by it Undiagnosed a lot of people receive partial treatment and live with the virulent bacteria for long before succumbing to it Often you have patients in the ICU who are not responding to treatment or whose situation is getting worse In such cases the doctors should suspect melioidosis and start treatment says ShrivastavWhile medicines such as ceftazidime and meropenem are available in the market Dr Direk Limmathurotsakul coauthor of the report says on email from Mahidol University in Thailand It needs to be used as a firstline drug and it can be used only if awareness of the doctor is highDavid Dance coauthor of research on melioidosisDavid Dance another author says These drugs are relatively expensive and often not used as the first choice They also need to be given for longer periods to patients with melioidosis than for some other infections and must be followed by long courses of oral antibiotics to get rid of the infection once and for allDance adds that the estimate that arose from their modelling was that there could be 52500 cases a year in India with a lsquocredible intervalrsquo from approximately 22000 125000 This is way in excess of the number of cases currently reported The modelling is based on a number of assumptions which might be incorrect or could be oversimplifications but even so this gives some idea of how big the size of the problem might be and should be a wakeup call for doctors laboratory staff and public health policy makers As more evidence becomes available the modelling can be refined to become more accurate So this is the beginning of a process and not the end point he says over emailNeed for awarenessWith dust soot or any particle that blocks the airways and inhibits the overall functioning of the immune system contributing to a greater susceptibility to melioidosis the responsibility of the government in funding research towards identifying prone areas and ensuring greater detection becomes crucialInterestingly melioidosis was brought to the state health departmentrsquos notice in the rsquo90s when researchers confused the plague caused by the yersinia pestis bacteriumwith the burkholderia pseudomalleiIn fact even five years ago we had warned the government that research needs to be funded to look at soil analysis across the country but it was rejected since the state wanted to concentrate on TB malaria and filarial says VeeraraghavanDr Deepak Sawant Maharashtrarsquos minister of public health and family welfare told SUNDAY midday that while a call on funding will be taken by the Union government the state will look at creating more awareness about the existence of melioidosis in Maharashtra especially training doctors to watch out for it