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Volume 28, Number 5—May 2022

Melioidosis in Children, Brazil, 1989–2019

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To the Editor: We read with great interest the article by Lima et al. (1), in which the authors have discussed 20 confirmed or suspected melioidosis cases in children over a period of 30 years, concluding that childhood melioidosis is more severe in Brazil. This conclusion seems far-fetched based on findings described in the article, although the authors state that the high death rate and clinical severity might have been attributed to underreporting of mild cases,

Melioidosis is not a notifiable disease in India. Even so, from a single tertiary-care teaching hospital at Odisha, we have reported >100 cases of culture-confirmed cases during 2016–2021 (24), of which 10 cases were in the pediatric population (8 cases of superficial pyogenic infections in otherwise healthy children and 2 cases of septicemic melioidosis). The second septicemic case was a 3-year-old girl with underlying acute lymphoblastic leukemia; she was treated with intravenous meropenem for 10 days and was discharged with a regimen of oral cotrimoxazole for 12 weeks.

Clinical severity of melioidosis is predominantly a function of host immunity (5). At a more pragmatic level, we would like to emphasize that, in melioidosis-endemic regions, most immunocompetent children with melioidosis experience localized infections and have better clinical outcomes, whereas in children with risk factors such as immunosuppression and childhood malignancies, the clinical course may be sudden and severe. In our view, frequent environmental exposures may not entirely explain the severity of childhood melioidosis. Lima et al. should have provided additional evidence to support their conclusion that childhood melioidosis is more severe in the population in Brazil.

Dr. Behera is an additional professor in the department of microbiology at All India Institute of Medical Sciences, Bhubaneswar, India. Her primary research interests are melioidosis, rickettsial diseases, and antimicrobial resistance.


Bijayini BeheraComments to Author , Anjuna Radhakrishnan, Sonali Mohapatra, and Baijayantimala Mishra
Author affiliation: All India Institute of Medical Sciences, Bhubaneswar, India



  1. Lima  RXR, Rolim  DB. Melioidosis in Children, Brazil, 1989-2019. Emerg Infect Dis. 2021;27:17058. DOIPubMedGoogle Scholar
  2. Behera  B, Mohanty  S, Mahapatra  A, Hallur  VK, Mishra  B, Dey  A, et al. Melioidosis in Odisha: a clinico-microbiological and epidemiological description of culture-confirmed cases over a 2-year period. Indian J Med Microbiol. 2019;37:4302. DOIPubMedGoogle Scholar
  3. Radhakrishnan  A, Behera  B, Mishra  B, Mohapatra  PR, Kumar  R, Singh  AK. Clinico-microbiological description and evaluation of rapid lateral flow immunoassay and PCR for detection of Burkholderia pseudomallei from patients hospitalized with sepsis and pneumonia: a twenty-one months study from Odisha, India. Acta Trop. 2021;221:105994. DOIPubMedGoogle Scholar
  4. Purushotham  P, Mohanty  S, Chappity  P, Mishra  TS, Mahapatra  A. Identification and characterization of Burkholderia pseudomallei from localized pyogenic infections in eastern India: a clinico-microbiological study. Am J Trop Med Hyg. 2021;104:12529. DOIPubMedGoogle Scholar
  5. Webb  JR, Sarovich  DS, Price  EP, Ward  LM, Mayo  M, Currie  BJ. Burkholderia pseudomallei lipopolysaccharide genotype does not correlate with severity or outcome in melioidosis: host risk factors remain the critical determinant. Open Forum Infect Dis. 2019;6:ofz091. DOIPubMedGoogle Scholar


Cite This Article

DOI: 10.3201/eid2805.211473

Original Publication Date: April 19, 2022

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In Response: We would like to respectfully clarify a few points in the comments by Behera et al. (1). We did not conclude that the severity of melioidosis in children in Brazil is greater than in other countries; we discussed it as a possibility (2). We also discussed that mild to moderate cases are the most prevalent forms in children and that they are underdiagnosed. However, it is possible that the severity of childhood melioidosis in Brazil may be like that in other melioidosis-endemic countries. By emphasizing disease severity, we aimed to draw attention to the detection of melioidosis in children, which can result in high death rates (3). Because the severe cases in our study occurred in healthy children, we did not discuss host immunity; this fact does not invalidate the role of immunity in melioidosis pathophysiology. Our objective was the same as that of Wiersinga et al. (4).

We described the intense environmental exposure of this age group in our region and recognized the importance of the environment to melioidosis epidemiology. We do not claim that exposure is the only explanation for disease severity, nor that it is a direct cause of severity. Furthermore, we acknowledge that human behavior and habits vary in different regions of the world; for example, tropical areas in which children play outdoors have a higher risk for melioidosis. Currie et al. have recommended additional studies (5).

We observed diverse genetic, cultural, and economic factors in the countries where melioidosis is found, whether it is well recognized or not. All of these factors could influence the distribution and severity of the disease (6). At this time, we believe a descriptive study can draw attention to melioidosis in tropical regions, such as Brazil and Latin American countries. The goal is to improve detection and reduce deaths from melioidosis in all parts of the world.

Rachel Lima, Universidade de Fortaleza, Washington Soares Av, 1321, Fortaleza 60811-905 Brazil
Author affiliations: Municipal Department of Health, Fortaleza, Brazil (R.X.R. Lima); University of Fortaleza Medical School (R.X.R. Lima, D.B. Rolim); Ceará State University, Fortaleza (D.B. Rolim)


  1. Behera  B, Radhakrishnan  A, Mohapatra  S, Mishra  B. Melioidosis in children, Brazil, 1989–2019. Emerg Infect Dis. 2022;•••: Epub ahead of print.
  2. Lima  RXR, Rolim  DB. Melioidosis in Children, Brazil, 1989-2019. Emerg Infect Dis. 2021;27:17058. DOIPubMedGoogle Scholar
  3. Wiersinga  WJ, Currie  BJ, Peacock  SJ. Melioidosis. N Engl J Med. 2012;367:103544. DOIPubMedGoogle Scholar
  4. Wiersinga  WJ, Virk  HS, Torres  AG, Currie  BJ, Peacock  SJ, Dance  DAB, et al. Melioidosis. Nat Rev Dis Primers. 2018;4:17107. DOIPubMedGoogle Scholar
  5. Currie  BJ, Jacups  SP. Intensity of rainfall and severity of melioidosis, Australia. Emerg Infect Dis. 2003;9:153842. DOIPubMedGoogle Scholar
  6. Limmathurotsakul  D, Golding  N, Dance  DAB, Messina  JP, Pigott  DM, Moyes  CL, et al. Predicted global distribution of Burkholderia pseudomallei and burden of melioidosis. Nat Microbiol. 2016;1:15008. DOIGoogle Scholar

Table of Contents – Volume 28, Number 5—May 2022

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Please use the form below to submit correspondence to the authors or contact them at the following address:

Bijayini Behera, AIIMS Bhubaneswar, Microbiology, 2nd Fl, Academic block, All India institute of Medical Sciences, Bhubaneswar, Bhubaneswar, Odisha 751019 India

Rachel Lima, Universidade de Fortaleza, Washington Soares Av, 1321, Fortaleza 60811-905 Brazil

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Page created: March 10, 2022
Page updated: April 20, 2022
Page reviewed: April 20, 2022
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