Imaging in Neuro-Melioidosis: Lessons from a Multi-centre Collaborative Effort Across India.

BACKGROUND AND PURPOSE: Neuro-melioidosis is an uncommon but potentially fatal manifestation of Burkholderia pseudomallei infection with diverse and often under-recognized imaging features. Existing imaging literature is limited to isolated reports and small series. We aimed to characterize the craniospinal MRI spectrum of neuro-melioidosis in a multicentre Indian cohort and identify recurrent imaging patterns associated with diagnostic delay.

MATERIALS AND

METHODS

In this retrospective multicentre case series, 33 patients with microbiologically confirmed neuro-melioidosis from seven Indian tertiary centres (2019-2025) underwent systematic neuroimaging review using a pre-defined data-collection template containing 40-variables. MRI features including lesion distribution, tract involvement, diffusion restriction, susceptibility abnormalities, enhancement patterns, meningeal disease, and spinal involvement were analysed descriptively alongside clinical and microbiological data.

RESULTS

Supratentorial involvement was present in 81.8% (27/33), infratentorial disease in 60.6% (20/33), and multifocal lesions in 60.6% (20/33). Brainstem involvement occurred in 57.6% (19/33). White matter tract dissemination was identified in 66.7% (22/33), with CST involvement in 63.6% (21/33); the "tunnel sign" was observed in 57.6% (19/33). Spinal involvement was present in 42.4% (14/33), including simultaneous brainstem and intramedullary disease in 33.3% (11/33). Diffusion restriction occurred in 72.7% (24/33), while SWI demonstrated haemorrhage or microbleeds in 36.4% (12/33). Initial misdiagnosis occurred in 24.2% (8/33), and 30.3% (10/33) received corticosteroids before definitive diagnosis. In-hospital mortality was 12.1% (4/33).

CONCLUSIONS

Neuro-melioidosis produced extensive craniospinal disease with a disproportionate frequency of brainstem, tract-based, and spinal involvement relative to other bacterial CNS infections. Recognition of this pattern together with blood, tissue, and/or CSF culture, which remain the diagnostic standard, may facilitate earlier diagnostic consideration and targeted microbiological evaluation in endemic settings.