Melioidosis, caused by Burkholderia pseudomallei, presents with diverse clinical manifestations. This is a case of a 1-year-old female presenting with fever, and altered sensorium. Her MRI had revealed features suggestive of brainstem encephalitis. Cerebrospinal fluid analysis confirmed the presence of Burkholderia pseudomallei. Treatment involved a two-phase antibiotic therapy: the acute phase and the eradication phase, and after 14 days of appropriate antibiotics, the patient stabilized and was discharged with follow-up care. This case underscores the importance of recognizing the rare neurological presentation of neuromelioidosis in pediatric patients, emphasizing the need for timely diagnosis and treatment to improve outcomes.

Burkholderia pseudomallei (B. pseudomallei) is a short, straight, medium-sized Gram-negative bacterium that mostly exists alone, without a capsule or spores, has more than three flagella at one end, and actively moves. B. pseudomallei confers high morbidity and mortality, with frequent granulocytopenia in B. pseudomallei sepsis-related deaths. However, mortality may be related to hemophagocytic lymphohistiocytosis (HLH) secondary to B. pseudomallei infection.

A 12-year-old female was referred from a local hospital to the pediatric intensive care unit with suspected septic shock and fever, cough, dyspnea, and malaise. After admission, supportive symptomatic treatments including fluid resuscitation, anti-infective therapy, mechanical ventilation, and a vasoactive drug maintenance cycle were carefully initiated. The patient became unconscious, her blood pressure could not be maintained even under the exposure of vasoactive drugs, and she experienced cardiorespiratory arrest. The patient died due to ineffective high-quality in-hospital cardiopulmonary resuscitation. A subsequent bone marrow smear examination revealed extensive phagocytosis, and the blood culture was positive for B. pseudomallei. Family history revealed a sibling death from B. pseudomallei sepsis 5 years earlier.

The higher mortality rate in patients with B. pseudomallei sepsis may be related to secondary HLH after infection, wherein multiorgan dysfunction syndrome may be directly related to infection or immune damage caused by secondary HLH. Patients with B. pseudomallei can be asymptomatic and can become an infective source.