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A 58-year-old diabetic male with hepatic cirrhosis presented with fever and vague bone pains. Technetium methylene diphosphonate (99mTc MDP) three phase bone scan (Figures 1 and ​and22) identified not only multiple sites of bone involvement but also extraskeletal renal involvement that was later proven by culture. Burkholderia pseudomallei was isolated from a blood culture, confirming a diagnosis of systemic melioidosis. Although lung abscess is the most common presentation disseminated disease often occurs, particularly in the presence of impaired host immunity, which was apparent in this patient. Pleural effusion, skin and soft tissue swellings, and liver and splenic abscesses may be encountered. Neurological involvement (brain stem encephalitis, cerebral abscess, cranial nerve palsies, and paraparesis), although less common, can be seen in 4% of cases.    Figure 1.  99mTc MDP regional three-phase bone scan showed multifocal bone involvement. Vascular and soft tissue phase images showed symmetrically increased vascularity and soft tissue tracer uptake in both knee joints. Increased soft tissue tracer uptake was noted ...Figure 2.  99mTc MDP whole-body bone scan. Skeletal phase images depict diffusely intense tracer uptake in the left femoral shaft with interspersed small cold defects. A hot spot is seen in left eighth rib posteriorly with associated increased tracer uptake in the ...    Melioidosis1 is a great masquerader, and it is often confused with staphylococcal abscesses in acute form, tuberculosis in chronic presentations, or a generalized sepsis. Aspirated pus may show caseating material similar to the material in tuberculosis, and tissue biopsy may show granuloma.

Multifocal Bone and Visceral Melioidosis in a Cirrhotic Patient Identified by 99mTc MDP Bone Scan