Hepatic Melioidosis: A State-of-the-Art Review.

Hepatic melioidosis is a clinically significant manifestation of Burkholderia pseudomallei infection, increasingly recognised across South and Southeast Asia. It primarily affects diabetic and immunocompromised individuals and is characterised by a subacute to chronic presentation that often mimics other causes of liver abscess. The pathogenesis of hepatic melioidosis reflects the interplay between bacterial virulence mechanisms and impaired host immunity, leading to intracellular persistence and necrotising hepatic lesions. Characteristic imaging features, including the honeycomb and necklace signs, aid in distinguishing melioidosis from pyogenic or amoebic abscesses. Microbiological confirmation remains the diagnostic gold standard but is frequently delayed by misidentification in automated systems. Management requires an intensive phase with intravenous ceftazidime or carbapenems, followed by an eradication phase with trimethoprim-sulfamethoxazole. Drainage is reserved for large, multiloculated abscesses or those that are poorly responsive to antibiotics. Hepatic melioidosis, though underdiagnosed, is an important cause of hepatic abscess in endemic regions. Awareness of its distinctive clinical, radiologic, and microbiologic features is essential for timely diagnosis and optimal management. Strengthening laboratory capacity and clinician familiarity can reduce misdiagnosis, guide appropriate therapy, and improve patient outcomes.