https://orcid.org/0000-0002-8022-1086
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Anjely Sebastian, Nitin Gupta, Muralidhar Varma, Chiranjay Mukhopadhyay, Necklace sign in Melioidosis, Journal of Travel Medicine, Volume 32, Issue 2, March 2025, taae147, https://doi.org/10.1093/jtm/taae147
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A 40-year-old male farmer with poorly controlled diabetes mellitus presented with complaints of fever and right-sided abdominal pain, along with loss of weight and appetite for 20 days. He had tender hepatomegaly measuring 3 cm below the right subcostal margin. Contrast Tomography of the abdomen showed two multiloculated heterogeneous lesions (segments VI and VIII) with a clear centre and locules arranged on the circumference in the form of necklace pearls (Figure 1). He underwent ultrasound-guided aspiration of pus, which grew Burkholderia pseudomallei in aerobic culture. He was treated with intravenous ceftazidime for four weeks, followed by oral trimethoprim-sulphamethoxazole for 12 weeks. He showed significant clinical and radiological resolution on follow-up.
Melioidosis is a tropical infection endemic in parts of Asia and Australia and is associated with high mortality.1 Isolated cases from Africa have also been reported.2 With increasing globalization, travel-related imported cases of melioidosis in Europe and the North Americas are not uncommon.1 The chronic forms of melioidosis are associated with multifocal abscesses, especially in the lungs, liver, spleen and prostate.3 Recently, the reversed halo sign on lung imaging, known to be commonly associated with mucormycosis, has also been described for lung abscesses due to melioidosis.4 Multiloculated abscesses in a honeycomb fashion have been described to be characteristic of liver abscesses due to melioidosis.3 In a large study, however, the honeycomb sign had a sensitivity and specificity of only 51% and 36%, respectively.5 The ‘necklace sign’ in the liver, on the other hand, has a very high specificity and is especially helpful in resource-limited settings where invasive procedures to establish a microbiological diagnosis are challenging.5 Treatment includes an intensive phase with meropenem or ceftazidime for 2 to 4 weeks, followed by an eradication phase with trimethoprim-sulphamethoxazole.
