Case Report: Eschar-like subcutaneous lesion in disseminated melioidosis revealing anti-interferon-γ autoantibody-associated adult-onset immunodeficiency and a review of the literature.

Background: Melioidosis, caused by the environmental saprophyte Case presentation: A 66-year-old woman from northeast Thailand with no known comorbidity presented with fever and chest pain 1 week after walking barefoot through floodwater. Contrast-enhanced computed tomography demonstrated mediastinal necrotic lymphadenitis and hepatosplenic microabscesses. Despite broad-spectrum β-lactam therapy, she remained febrile and, on illness day 8, developed a painful subcutaneous nodule that evolved within 2 days into a dark, eschar-like lesion. Pus culture grew Conclusion: A structured review identified only six previously published patients with an eschar or eschar-like necrotic lesion in culture-confirmed melioidosis; the majority, as in our patient, had disseminated disease, and almost all had a documented soil or freshwater exposure. Melioidosis should be considered in patients with rapidly progressive visceral abscesses and necrotic skin lesions in the weeks after flooding or other heavy freshwater exposure in endemic regions, and unexplained severity should prompt evaluation for anti-interferon-γ autoantibody-associated immunodeficiency together with confirmation of unusual resistance phenotypes. As flooding becomes more frequent, clinical awareness and simple protective measures during and after floods are likely to be increasingly important.