The µGnome has not been known to turn down the chance of a germ hunt in distant parts, but there has to be an exception – a journey well beyond the µGnome’s garden fence without the solace of a fishing rod. This is the story of The Expedition; the one that led to so many subsequent forays.

The call for help came, as is so often the case, out of the blue. It was an unsolicited e-mail from the Health Secretariat in a small state on the northeast of Brazil (Figure 1). They had had a small outbreak of an unusual tropical infection and there had been deaths (1-3). FIOROCRUZ in Rio had confirmed the suspicions of an astute pathologist that this was not plague, but something previously unreported in northern Brazil; a disease called melioidosis. The authorities were notified. People flew in from Brasilia with an Atlanta-based expert from the Centers for Disease Control and Prevention.

Fig 1. Colonial style buildings in Fortaleza, Brazil

The public health experts tramped around a small farm in the semi-arid western part of Ceará, stroked their chins, scratched their heads and left with more questions than answers: was it really melioidosis, were there more undetected cases, and why had it happened there and then?

The µGnome had a few suggestions for case finding and environmental sampling, which he happily sent in a series of e-mails. The volume of e-mail traffic increased. Articles were translated into Portuguese. The Secretariat got to work on the problem with a vengeance. But then reports came in of a Dutch tourist who had died after an eco-holiday in Western Ceará (4). The pressure was on to do something more, like persuade the µGnome to pay a visit. After a lot of arm-twisting via the Net, the µGnome left his fishing rod behind, closed the garden gate on his comfort zone and took flight via Santiago and São Paulo for Fortaleza. On his insistence, µGnome had the services of an interpreter who had already translated several of the journal publications from English into Brazilian Portuguese. These delightful people (Fig 2) were serious about getting to the root of their outbreak.

Fig 2. Melioidistas, Fortaleza, 2004

µGnome set out a game plan in a preliminary team brief based on a SMEAC format, and we were off. The Secretariat put a couple of vehicles and a heap of staff at our disposal, and gave us free access to everything we considered relevant. The heroes of the piece were the three Ds (Diana, Dionne and Dina), Iracema and Anastacio. Between them, they coaxed and coached µGnome in the most elementary aspects of Portuguese communication as we rumbled around in the vehicle.

We took a look at the State public health laboratory where the bacteria had been processed, assessing what needed to be done to speed up identification procedures (Fig 3). We did a round in the Hospital Sao Jose to see the support available to patients with serious infections. We headed out West to the small market town of Tejuçuoca for meetings with public health officials, then went out to the now abandoned goat ranch (fazenda, Fig 4) where the victims had fallen foul of this infection. It was the dry season, so the dam the children had dived from was empty. We could only imagine what it must have looked like after the rains arrived.

Fig 3. Burkholderia pseudomallei colonies on a blood agar plate

Fig 4. Abandoned farmhouse where outbreak victims lived

On our way back to Fortaleza we stopped over at the Ecotourism centre to see where the Dutch tourist had stayed. The project was a well-meant introduction to the possibilities of environmentally sustainable agriculture in the marginal conditions of the coastal hinterland. Apart from nature rambles, livestock gazing (not for men who stare at goats) and the aesthetic aspects of composted waste there was little to do. But that, the µGnome noted, is missing the point. This has to be a part of the planet where you go to unwind. The main benefit of the road less travelled is that busy people have to travel slowly, if at all (Fig 5).

Fig 5. The road less travelled

However, we did have a look at an impressive bat cave and concluded that a condition called histoplasmosis might be a risk. Not to mention some of the more exotic bat-transmitted viral infections. On our return to the big smoke of Fortaleza, we took a wander round the local market to get a feel for the state’s agriculture.  For budding melioidistas, the discovery of locally grown rice was a special moment since rice farmers are a recognised risk group for the infection (Fig 6).

Fig 6. Rice grown in northern Brazil

Outcomes

µGnome returned home with some swabs and blood samples for lab tests, a bundle of new friends and a determination to add to his small collection of Portuguese phrases.

Together, we wrote up our early investigations (5), set them in a bigger picture context (6), and floated the outrageous idea that the infection might have its origins in the Americas during the colonial era (7). Subsequent whole genome analysis appears to point to an origin closer to µGnome’s home, but he has yet to see a serious attempt to disprove the idea that the bacteria that cause melioidosis might have been shipped around with rubber, which also came from Brazil. We’ve also put together a couple of guidelines for local practitioners and a confirmatory lab method, publishing them in the local literature (8,9).  A more detailed picture of melioidosis and its ecology is now beginning to emerge from Northeastern Brazil, now that local specialists have established a series of laboratory methods (10-12).

µGnome

References

1. Miralles IS, Maciel Mdo C, Angelo MR, Gondini MM, Frota LH, dos Reis CM, Hofer E. Burkholderia pseudomallei: a case report of a human infection in Ceará, Brazil. Rev Inst Med Trop Sao Paulo. 2004; 46: 51-4.
2. Braga MD, Almeida PR. [First description of an autopsied case of melioidosis in Ceará State] Rev Soc Bras Med Trop. 2005; 38: 58-60.
3. Tavares W. [Melioidosis in a little rural community of Ceará State] Rev Soc Bras Med Trop. 2005; 38: 276.
4. Aardema H, Luijnenburg EM, Salm EF, Bijlmer HA, Visser CE, Van’t Wout JW. Changing epidemiology of melioidosis? A case of acute pulmonary melioidosis with fatal outcome imported from Brazil. Epidemiol Infect. 2005; 133: 871-5.
5. Rolim DB, Vilar DC, Sousa AQ, Miralles IS, de Oliveira DC, Harnett G, O’Reilly L, Howard K, Sampson I, Inglis TJ. Melioidosis, northeastern Brazil. Emerg Infect Dis. 2005; 11: 1458-60.
6. Inglis TJ, Rolim DB, Sousa Ade Q. Melioidosis in the Americas. Am J Trop Med Hyg. 2006; 75: 947-54.
7. Inglis TJ, Sagripanti JL. Environmental factors that affect the survival and persistence of Burkholderia pseudomallei. Appl Environ Microbiol. 2006 Nov;72(11):6865-75
8. Inglis TJ, Rolim DB, Rodriguez JL. Clinical guideline for diagnosis and management of melioidosis. Rev Inst Med Trop São Paulo. 2006; 48: 1-4.
9. Inglis TJ, Sousa AQ. The public health implications of melioidosis. Braz J Infect Dis. 2009; 13: 59-66.
10. Rolim DB, Rocha MF, Brilhante RS, Cordeiro RA, Leitão NP Jr, Inglis TJ, Sidrim JJ. Environmental isolates of Burkholderia pseudomallei in Ceará State, northeastern Brazil. Appl Environ Microbiol. 2009; 75: 1215-8.
11. Virginio CG, Teixeira MF, Frota CC, Café VS, Rocha MF, Sidrim JJ. Phenotypic characterization of three clinical isolates of Burkholderia pseudomallei in Ceará, Brazil. Mem Inst Oswaldo Cruz. 2006; 101: 95-7.
12. Couto MS, Cordeiro Rde A, Rocha MF, Grangeiro TB, Leitão Junior NP, Bandeira Tde J, Sidrim JJ, Brilhante RS. A diagnosis of Burkholderia pseudomallei directly in a bronchoalveolar lavage by polymerase chain reaction. Diagn Microbiol Infect Dis. 2009; 65: 73-5.

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