AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Glanders and melioidosis are related diseases produced by bacteria of the Burkholderia species, which are gram-negative rods. They produce similar symptoms and have similar pathophysiologic consequences. Glanders and melioidosis are of interest because of significant study for potential weaponization by the United States and other countries in the past. During World War I, glanders was believed to have been spread to infect large numbers of Russian horses and mules on the Eastern Front. The Japanese infected horses, civilians, and prisoners of war during World War II. The United States studied this agent as a possible biological warfare (BW) weapon in 1943-1944 but did not weaponize it. The former Soviet Union is believed to have been interested in glanders as a potential BW weapon as well.

Burkholderia mallei (nonmotile, nonsporulating, obligate aerobic, gram-negative bacillus) is the causative agent of glanders, primarily a disease of animals such as horses, mules, and donkeys. Glanders has been only a rare and sporadic disease in humans, and no epidemics have been reported. In China during World War II, 30% of the tested horses were infected with glanders, but human cases were rare. The reason for the low transmission rate is not known. In the human population, it typically is found in those with close and frequent contact with infected animals, such as veterinarians, animal caretakers, abattoir workers, and laboratory personnel.

Melioidosis, also known as Whitmore disease, is caused by the bacterium Burkholderia pseudomallei (a motile, aerobic, non–spore-forming bacillus). It is clinically similar to glanders disease, although the epidemiology differs. The bacteria thrive in tropical climates, and the disease is endemic in Southeast Asia and Australia, but it is found in the Middle East, India, and China (essentially tropical areas between latitudes 20 degrees north and south). Sporadic melioidosis cases have been reported in the United States (typically 0-5 cases per year, usually among immigrants and travelers). Both humans and other susceptible animals may contract the disease.

Both organisms are considered potential BW agents, especially in the aerosolized form.

Pathophysiology

Glanders is caused by B mallei (formerly Pseudomonas mallei). The bacteria only exist in infected susceptible hosts and are not found in water, soil, or plants. In nature, humans typically acquire glanders from equids via direct contact with broken skin or mucous membranes. While transmission through intact skin has been reported, it is not well documented. A secondary mode of transmission can be through inhalation of droplets from an infected equid or patient. Once in the host, synthesis and release of certain toxins occur. Usually, the amount is insignificant, and no clinical disease process ensues. However, if a large quantity of the organism is incorporated, the amount of toxin is sufficient to cause specific symptoms. Antibiotics are of little use. The toxins include pyocyanin (blue-green pigment that interferes with the terminal electron transfer system), lecithinase (causes cell lysis by degrading lecithin in certain cell membranes), collagenase, lipase, and hemolysin.

Melioidosis is an infectious disease caused by B pseudomallei (formerly Pseudomonas pseudomallei). The organism is distributed widely in the soil and water of the tropics. It is spread to humans through direct contact with a contaminated source, especially during the rainy season. The disease usually occurs in the fourth and fifth decades of life, especially among those who have chronic comorbidities such as diabetes and renal failure. B pseudomallei is considered a good candidate as a bioweapon because it is easily available in the tropics, it is fairly easy to cultivate, it is sturdy, and it has a high potential to become bacteremic, thereby increasing morbidity and mortality. The incubation period in naturally acquired infections can vary from days to months to years. The incubation period after an aerosol attack is expected to be from 10-14 days.

Glanders and melioidosis produce similar clinical syndromes.

Localized form

Bacteria enter the skin through a laceration or abrasion, and a local infection with ulceration develops. The incubation period is 1-5 days. Swollen lymph glands may develop. Bacteria that enter the host through mucous membranes can cause increased mucus production in the affected areas.

Pulmonary form

When bacteria are aerosolized and enter the respiratory tract via inhalation or hematogenous spread, pulmonary infections may develop. Pneumonia, pulmonary abscesses, and pleural effusions can occur. The incubation period is 10-14 days. With inhalational melioidosis, cutaneous abscesses may develop and take months to appear.

Septicemia

When bacteria is disseminated in the bloodstream in glanders, it is usually fatal within 7-10 days. The septicemia that develops affects multiple systems, and cutaneous, hepatic, and splenic involvement may occur. With melioidosis, bacteremia is observed with chronically ill patients (eg, patients with HIV, patients with diabetes). They develop respiratory distress, headaches, fever, diarrhea, pus-filled lesions on the skin, and abscesses throughout the body. Septicemia may be overwhelming, with a 90% fatality rate and death occurring within 24-48 hours.

Chronic form

The chronic form involves multiple abscesses, which may affect the liver, spleen, skin, or muscles. This form also is known as farcy in glanders disease. Melioidosis, in addition to this chronic form, can become reactive many years after the primary infection.

Frequency

United States

Glanders was eliminated from US domesticated animals in the 1940s. One recent human case of glanders in a laboratory worker occurred in 2000. This is the first human case reported in the United States since 1945.¹

A few isolated cases of melioidosis have occurred in the United States. Confirmed cases range from 0-5 each year and occur among travelers, immigrants, and intravenous drug users.

International

Glanders is endemic in Africa, Asia, the Middle East, Central America, and South America.

Melioidosis is endemic in Southeast Asia and northern Australia. It has been observed in the South Pacific, Africa, India, the Middle East, Central America, and South America.

Mortality/Morbidity

• Glanders is primarily zoonotic. It is rare in humans, and no epidemics have been reported. The mortality rate in the pulmonary form of glanders is 90-95% if untreated and 40% if treated. The mortality rate in the septicemic form of glanders is greater than 95% if untreated and 50% if treated. The mortality rate in the cutaneous form of glanders is 90-95% if it becomes systemic and if untreated and 50% if treated. For the chronic form of glanders, the mortality rate may be 50% despite treatment.
• Melioidosis has had a reported mortality rate from 10% up to 90% if disseminated septicemia is present. It is most widespread in Thailand, where in one hospital, it was responsible for 19% of community-acquired sepsis and 40% of deaths from community-acquired septicemia.² The fatality rate of melioidosis is greater in people with specific comorbidities, such as diabetes mellitus, renal dysfunction, or chronic pulmonary disease, and in people who are immunosuppressed for one reason or another.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• Glanders is transmitted to humans through direct skin or mucous membrane contact with infected animal tissues. Cases of human-to-human transmission have been reported.
• Melioidosis is transmitted to humans through direct skin contact with contaminated soil or water. Ingestion of contaminated water and inhalation of dust contaminated with the organism are other mechanisms of transmission. Cases of human-to-human transmission are rare but have been documented.
• Generalized symptoms include fever, rigors, night sweats, myalgia, anorexia, and headache. Additional symptoms, which are based on the route of exposure, include chest pain, cough, photophobia, lacrimation, and diarrhea.

Physical

Physical findings may include fever, cervical adenopathy, papular or pustular skin lesions, hepatomegaly, or splenomegaly.

• Severe urticaria has been reported during primary melioidosis.
• During septicemia, flushing, cyanosis, and a disseminated pustular eruption can be seen. Pustules often are associated with regional lymphadenitis, cellulitis, or lymphangitis.
• Rarely, ecthyma gangrenosum–like lesions and cutaneous abscesses (that sometimes ulcerate) may develop.

Specifically, in melioidosis septicemia, high fevers and rigor are present. These findings may be accompanied by confusion, dyspnea, abdominal pain, muscle tenderness, pharyngitis, diarrhea, and jaundice. While the typical foci in these severe cases begin from the skin or the lungs, metastasis (liver, spleen, kidney, brainstem, parotid gland) will occur, leading to acidosis, shock, and death within 48 hours of presentation. 

Causes

• Human cases of glanders have occurred primarily in occupational settings and include laboratorians, veterinarians, and animal caretakers.
• Human cases of melioidosis have occurred from sexual contact and intravenous drug use. It has been observed in immigrants, military personnel, and travelers.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Complete blood count: Complete blood count may reveal a mild leukocytosis with a left shift or leukopenia. With glanders, the WBC is often normal or minimally elevated. Elevated liver enzyme levels in glanders may signify hepatic abscess formation.
• In melioidosis specifically, laboratory studies may demonstrate anemia, leukocytosis, hepatic impairment, renal insufficiency, and coagulopathy.
• Gram stain and culture of blood, sputum, urine, and skin lesions
• • Blood culture results may be negative. The median time for growth is 48 hours. Ironically, in septicemic melioidosis, blood culture results may be negative until just before death.
  • Gram stain and culture of sputum, urine, and skin lesions can be performed. Gram stain may reveal small, gram-negative bacilli, which stain irregularly with methylene blue or Wright stain, and they may demonstrate a safety pin bipolar appearance.
  • Meat nutrient agar or the addition of 1-5% glucose may accelerate growth of bacteria. Another useful culture medium for B pseudomallei is Ashdown's selective medium.
• Agglutination tests: Agglutination test results may be positive after 7-10 days, but a high background titer found in normal sera makes interpretation difficult.
• Indirect hemagglutination tests
• Polymerase chain reaction assays
• Immunofluorescence assays
• Enzyme immunoassays
• Complement fixation tests
• • Complement fixation tests are more specific and are considered positive for glanders if the titer is equal to or greater than 1:20.
  • A 4-fold increase in the titer for melioidosis is considered positive.

Imaging Studies

• Chest radiography may demonstrate bilateral bronchopneumonia, miliary nodules, segmental or lobar infiltrates, and cavitating lesions. With melioidosis, an abnormal chest radiography finding is present in up to 80% of patients (usually diffuse nodular shadowing).

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Prehospital Care

Use standard precautions (ie, use of disposable surgical masks, face shields, and gowns when appropriate) to prevent human-to-human transmission.

Emergency Department Care

• Implement barrier protection with secretion precautions. While person-to-person transmission is unlikely, isolation rooms for these patients are advisable. Patients should be masked to prevent droplet dissemination.
• Obtain radiography, and collect blood, urine, sputum, and skin lesion fluid.
• Initiate rapid administration of supportive care and intravenous antibiotic therapy for severe disease.

Consultations

• Glanders and melioidosis are reportable diseases; notify local health authorities of suspected cases.
• Occurrence of glanders in the absence of animal attack, occupational exposure, and/or in an epidemic is presumptive evidence of a BW attack. Consultation with an infectious disease specialist, the Centers for Disease Control and Prevention, and the Federal Bureau of Investigation may be warranted.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Limited information exists about antibiotic therapy for these conditions in humans because clinical studies examining antibiotic effectiveness in vivo are rare. For localized disease, a 60- to 150-day course of oral amoxicillin and clavulanate, doxycycline, or trimethoprim and sulfamethoxazole (TMP-SMX) may be used.

For local disease with mild toxicity, combine 2 of the 3 regimens for 30 days, then switch to monotherapy with amoxicillin and clavulanate or TMP-SMX for 60-150 days.

For extrapulmonary suppurative disease, prolong treatment for 6-12 months. Drain abscesses surgically. For severe and/or septicemic disease, initiate parenteral therapy for 2 weeks followed by oral therapy for 6 months (ceftazidime combined with TMP-SMX 8 mg TMP/kg/d and 40 mg SMX/kg/d divided qid). Add streptomycin when initiating treatment if plague cannot be excluded. 

Alternative choices in severe cases of melioidosis include imipenem-cilastatin or meropenem with or without trimethoprim/sulfamethoxazole. Administration of these drugs may continue for up to 4 weeks depending on clinical response. Then, a 20-week course of doxycycline and trimethoprim/sulfamethoxazole, which is said to minimize the likelihood of relapse better than amoxicillin-clavulanic acid, is administered. The prevention of relapse in melioidosis is critical since it has been reported to occur in 23% of cases. Hence, the rational behind the prolonged therapy. Other antibiotics with activity against B pseudomallei include ceftriaxone ticarcillin-sulbactam, and aztreonam.

Currently, no proven preexposure or postexposure prophylaxis is available. Postexposure prophylaxis with TMP-SMX may be attempted. No vaccine is available for human glanders or melioidosis.

One melioidosis treatment protocol at the Royal Darwin Hospital in Australia consists of the following: ceftazidime 2 g IV q6h (50 mg/kg up to 1 g in children) for at least 14 days or meropenem 1 g IV q8h for at least 14 days (25 mg/kg up to 1 g in children) coupled with cotrimoxazole 320/1600 mg PO/IV bid for at least 14 days (8/40 mg/kg up to 320/1600 mg in children). This protocol is for moderate-to-severe manifestations and may have to be continued for more than 14 days. Once the acute episode is resolved, then the eradication period would commence.³

For systemic glanders, initial therapy should consist of imipenem, ceftazidime, or meropenem plus either ciprofloxacin or doxycycline. Intravenous therapy may last as long as 2-3 weeks followed by a switch to oral antibiotics (ciprofloxacin, doxycycline, TMP/SMX, or amoxicillin/clavulanate) for up to 150 days in order to prevent reactivation (most authors believe a total of 24 weeks is advisable).⁴

Drug Category: Antibiotics

Base choice of antibiotic and route of administration on the clinical setting.

Drug Name	Tetracycline (Minocin)
Description	Primarily bacteriostatic and believed to exert antimicrobial effect by inhibition of protein synthesis.
Adult Dose	40 mg/kg/d PO divided tid
Pediatric Dose	<8 years: Not recommended >8 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Concurrent use may render oral contraceptives less effective; demonstrated to depress plasma prothrombin activity; patients receiving anticoagulant therapy may require downward adjustment of anticoagulant dosage; because bacteriostatic drugs may interfere with bactericidal action of penicillin, avoid administering tetracycline-class drugs in conjunction with penicillin; absorption is impaired by antacids containing aluminum, calcium, or magnesium and by iron-containing preparations; concurrent use of methoxyflurane has been reported to result in fatal renal toxicity
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Pseudotumor cerebri (benign intracranial hypertension) in adults has been associated with use; photosensitivity manifested by exaggerated sunburn reaction has been observed in some individuals; persons with impaired renal function may require a lower dose

Drug Name	Sulfamethoxazole and trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)
Description	SMX inhibits bacterial synthesis of dihydrofolic acid by competing with PABA. TMP blocks production of tetrahydrofolic acid from dihydrofolic acid by binding to and reversibly inhibiting the required enzyme, dihydrofolate reductase; thus, it blocks 2 consecutive steps in biosynthesis of nucleic acids and proteins essential to many bacteria.
Adult Dose	Local or mild disease: 4 mg TMP/kg/d and 20 mg SMX/kg/d PO divided bid Severe disease: 8 mg TMP/kg/d and 40 mg SMX/kg/d IV divided qid for 2 wk; then PO for 6 mo
Pediatric Dose	<2 months: Not recommended >2 months: Administer as in adults
Contraindications	Documented hypersensitivity; documented megaloblastic anemia due to folate deficiency; pregnant patients and breastfeeding mothers (sulfonamides cross the placenta, are excreted in milk, and may cause kernicterus)
Interactions	Increased incidence of thrombocytopenia with purpura has been reported in elderly patients concurrently receiving certain diuretics (primarily thiazides); may prolong PT in patients receiving warfarin; may inhibit hepatic metabolism of phenytoin (be alert for possible excessive phenytoin effect); sulfonamides also can displace methotrexate from plasma protein binding sites, thus increasing free methotrexate concentrations
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions	Renal or hepatic function, folate deficiency, G-6-PD deficiency, and severe allergies or bronchial asthma; local irritation and inflammation due to extravascular infiltration of the infusion have been observed with IV

Drug Name	Amoxicillin and clavulanate (Augmentin)
Description	Semisynthetic antibiotic with a broad spectrum of bactericidal activity against many gram-positive and gram-negative microorganisms. Susceptible to degradation by beta-lactamases, and, thus, spectrum of activity does not include organisms that produce these enzymes. Clavulanic acid is a beta-lactam, structurally related to penicillins, which possesses ability to inactivate a wide range of beta-lactamase enzymes commonly found in microorganisms resistant to penicillins and cephalosporins. Formulation of amoxicillin and clavulanic acid protects amoxicillin from degradation by beta-lactamase enzymes and effectively extends antibiotic spectrum of amoxicillin to include many bacteria normally resistant to amoxicillin and other beta-lactam antibiotics. Possesses properties of a broad-spectrum antibiotic and a beta-lactamase inhibitor.
Adult Dose	60 mg/kg/d PO divided tid for local disease or mild toxicity
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity; history of Augmentin-associated cholestatic jaundice and/or hepatic dysfunction
Interactions	Probenecid decreases renal tubular secretion of amoxicillin; concurrent use may result in increased and prolonged blood levels of amoxicillin; coadministration of probenecid cannot be recommended; concurrent administration of allopurinol and ampicillin substantially increases incidence of rashes in patients receiving both drugs compared to patients receiving ampicillin alone; unknown whether this potentiation of ampicillin rashes is due to allopurinol or hyperuricemia present in these patients; no data exist with Augmentin and allopurinol administered concurrently; as with other broad-spectrum antibiotics, may reduce efficacy of oral contraceptives
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Hepatic dysfunction; renal impairment

Drug Name	Streptomycin
Description	Aminoglycoside antibiotic recommended when less potentially hazardous therapeutic agents are ineffective or contraindicated.
Adult Dose	30 mg/kg/d IM; not to exceed 2 g/d
Pediatric Dose	25-30 mg/kg/d IM; not to exceed 1-1.5 g/d
Contraindications	Documented hypersensitivity; non-dialysis-dependent renal insufficiency
Interactions	Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, and loop diuretics
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Pregnancy; narrow therapeutic index; not intended for long-term therapy; caution in patients with renal failure who are not on dialysis; caution with myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission

Drug Category: Antibiotic, Anaerobic

Drug Name	Imipenem and cilastatin (Primaxin)
Description	For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.
Adult Dose	Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250-500 mg q6h IV for a maximum of 3-4 g/d Alternatively, 500-750 mg q12h IM or intra-abdominally
Pediatric Dose	Infants >3 months and children <12 years: 15-25 mg/kg/dose IV q6h Fully susceptible organisms: Not to exceed 2 g/d Infections with moderately susceptible organisms: Not to exceed 4 g/d >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)
Interactions	Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions	Adjust dose in renal insufficiency (adult adjustments) CrCl (mL/min) 80-50: 0.5 g q6-8h CrCl 50-10: 0.5 g q8-12h Hemodialysis (HD): 0.25-0.5 g after HD, then q12h Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections Caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta-lactam antibiotics

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Deterrence/Prevention

• Biosafety level 3 containment practices are required for laboratory staff when working with these organisms.
• In countries where glanders is endemic in animals, identification and elimination of the disease in the animal population prevents disease in humans.
• In areas where melioidosis is endemic, persons who have chronic illnesses that lead to an immunocompromised state should avoid contact with soil and standing water. Wearing boots and gloves during agricultural work is advised.

Complications

• Possible complications include septicemia, osteomyelitis, meningitis, and brain, liver, or splenic abscess.

Prognosis

• Untreated patients with septicemia have fatal outcomes. Before antibiotics, the death rate for septicemic disease was 95%. It is greater than 50% for septicemic disease and 20% for localized disease despite treatment. Overall, the mortality rate is 40%.

Patient Education

• For excellent patient education resources, visit eMedicine's Bioterrorism and Warfare Center. Also, see eMedicine's patient education articles Biological Warfare and Personal Protective Equipment.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Several obstacles to understanding these diseases exist. These include lack of awareness among clinicians resulting in delayed diagnosis or misdiagnosis; absence of diagnostic laboratories with adequate, standardized serologic methods to detect these rare organisms; inadequate surveillance systems; and a lack of research. More studies are needed on all aspects of these diseases, as is a heightened level of awareness among health care providers.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Dahna Batts, MD, Alan H Hall, MD, and Thomas W McGovern, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

1. Centers for Disease Control and Prevention. Laboratory-acquired human glanders--Maryland, May 2000. MMWR Morb Mortal Wkly Rep. Jun 23 2000;49(24):532-5. [Medline].
2. Montgomery S. Burkholderia pseudomallei (melioidosis) Attack. In: Ciottone GR, Anderson PD, Auf Der Heide E, Darling RG, Jacoby I, Noji E, Suner S. Disaster Medicine. 3^rd ed. Philadelphia, PA: Mosby/Elsevier; 2006:chap 115; 650-652.
3. Dance DA. Melioidosis as an emerging global problem. Acta Trop. Feb 5 2000;74(2-3):115-9. [Medline].
4. Graber MA. Burkholderia mallei (glanders) attack. In: Ciottone GR, Anderson PD, Auf Der Heide E, Darling RG, Jacoby I, Noji E, Suner S. Disaster Medicine. 3^rd ed. Philadelphia, PA: Mosby/Elsevier; 2006:chap 114; 647-649.
5. CDC Strategic Planning Workgroup. Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep. Apr 21 2000;49(RR-4):1-14. [Medline].
6. Centers for Disease Control and Prevention. Imported melioidosis--South Florida, 2005. MMWR Morb Mortal Wkly Rep. Aug 18 2006;55(32):873-6. [Medline].
7. Institute for International Cooperation in Animal Biologics. Glanders. Last updated January 2004. The Center for Food Security & Public Health (Iowa State University). Available at www.cfsph.iastate.edu/Factsheets/pdfs/glanders.pdf. Accessed June 13, 2007.
8. Institute for International Cooperation in Animal Biologics. Melioidosis. Last updated October 2005. The Center for Food Security & Public Health (Iowa State University). Available at www.cfsph.iastate.edu/Factsheets/pdfs/melioidosis.pdf. Accessed June 13, 2007.
9. Ko WC, Cheung BM, Tang HJ, Shih HI, Lau YJ, Wang LR, et al. Melioidosis outbreak after typhoon, southern Taiwan. Emerg Infect Dis. Jun 2007;13(6):896-8. [Medline].
10. McGovern TW, Christopher GW, Eitzen EM. Cutaneous manifestations of biological warfare and related threat agents. Arch Dermatol. Mar 1999;135(3):311-22. [Medline].
11. Short BH. Melioidosis: an important emerging infectious disease - a military problem?. ADF Health. Apr 2002;3:13-21.
12. Thummakul T, Wilde H, Tantawichien T. Melioidosis, an environmental and occupational hazard in Thailand. Mil Med. Sep 1999;164(9):658-62. [Medline].
13. USAMRIID. Glanders and Melioidosis. Accessed January 28, 2005. Available at http://navymedicine.med.navy.mil/Files/Media/directives/5042.pdf.
14. USAMRIID. Glanders and melioidosis. In: Biological Warfare and Terrorism: Medical Issues and Response. 2000:21-25.

Article Last Updated: Aug 14, 2007