61: From Fatal to Beatable — Pediatric Systemic Malleidosis with Severe PARDS: A First Survival Story

Background: Melioidosis, caused by Burkholderia pseudomallei, is a potentially fatal but under-recognized infection in children due to its diverse presentation and low diagnostic sensitivity. Severe systemic melioidosis causing acute respiratory distress syndrome (ARDS) and requiring extracorporeal membrane oxygenation (ECMO) is exceedingly rare in the pediatric population. Case Description: A previously healthy 4-year-10-month-old girl presented with fever, abdominal pain, myalgia, and rapidly progressive respiratory distress. Laboratory evaluation showed leukopenia, thrombocytopenia, and elevated inflammatory markers. Chest imaging revealed bilateral infiltrates. History revealed swimming in a resort pool. Despite rescue therapies—including prone ventilation, high-frequency oscillatory ventilation, inhaled nitric oxide, and continuous neuromuscular blockade—she developed refractory hypoxemia and was initiated on veno-venous ECMO. Blood cultures grew Burkholderia pseudomallei, confirming systemic melioidosis. She received targeted antimicrobial therapy following the Darwin protocol (meropenem followed by trimethoprim-sulfamethoxazole). After 7 days on ECMO, she was successfully decannulated and extubated. Follow-up demonstrated full recovery with normal chest imaging. Conclusion: Severe systemic melioidosis with ARDS requiring ECMO, though extremely uncommon, can be successfully managed with early diagnosis, targeted antimicrobial therapy, and timely extracorporeal support. This case represents the first documented pediatric survival of melioidosis-associated ARDS managed with ECMO.