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The boy's parents weren't convinced that their 5-year-old had died of COVID-19, so they insisted on an autopsy.

The hospital where he died declined to do one, as did the local medical examiner. His case ended up in the hands of Rachel Geller, MD, an associate medical examiner in Georgia's DeKalb County.

Geller's findings ultimately led to the smoking gun in a deadly melioidosis outbreak that CDC investigators detailed in the in March 2022.

"I think his case highlights the importance of autopsy, even when we think we already have all the answers," Geller told MedPage Today. "Sometimes we might not be asking the right questions."

It's not clear that the culprit product -- an aromatherapy spray sold at Walmart -- would have been caught as quickly without this autopsy, as it was discovered after an exhaustive search of the boy's home. But Geller lamented the continued decline in autopsies, which can overturn diagnoses and reveal "clinically significant findings," she said.

Wrong Diagnosis

Since the child had reportedly died after an adult-like presentation of SARS-CoV-2 infection, Geller suspected she might find heavy red lungs -- a sign of the alveolar damage often seen in adult COVID deaths -- or perhaps consolidation of lung tissue, a sign of pneumonia.

Instead, she found "numerous green-white, pearly abscesses diffusely involving the lower lobes of the lungs," surrounded by areas of severe pneumonia, she told MedPage Today. The child's brain had areas of softening and hemorrhage. He also had microabscesses in his brain and liver, which were revealed on microscopy, she said, and he had hemorrhagic adrenal glands, which is sometimes seen in severe bacterial infection.

Geller said she realized a bacterial infection, and not solely COVID-19, was likely to blame for the child's death. She sent samples to Wayne Wang, MD, PhD, director of microbiology at Grady Memorial Hospital in Atlanta.

It was a Saturday, outside of normal working hours, when a lab tech discovered the boy had been infected with Burkholderia pseudomallei, a rare and deadly bacteria not typically found in the U.S. It's more commonly found in contaminated soil and water in tropical or subtropical climates.

"If you see an organism in the category of potential bioterrorism, you stop what you're doing," Wang told MedPage Today. "You don't work it up further. You contact [the CDC] Lab Response Network and the state [health department] lab; that's protocol. Our tech followed protocol."

By the end of July, the state lab had confirmed Burkholderia pseudomallei infection, and sent the samples on to the CDC, which also confirmed the bacteria within a few days, Wang said.

Cracking the Case

The first case of melioidosis was reported to CDC in March 2021, in a woman from Kansas, age 53, with no travel history, although the isolate looked like it came from South Asia, according to William Bower, MD, epidemiology team lead for the bacterial special pathogens branch at the CDC in Atlanta.

The second case occurred in late May 2021 in a girl from Texas, age 4 years, who also had no travel history. But the isolate strain was a match to the Kansas case, Bower told MedPage Today.

"These people had no interaction with each other, they lived in different states, and it happened over a few weeks," Bower said. "That was when we really thought this was unique."

A third case followed not long after that, in Minnesota man, age 53, and again, the isolate was a match. Geller's Georgia case, reported in July, shared a common genetic origin, too.

CDC investigators had been looking for a source in a product, likely imported from Southeast Asia, that was in liquid form or "at least had some moisture content in it," Bower said. "We asked family members about products with moisture, like salves or sprays."

Scores of products were sampled, with no luck. Only on a second visit to the Georgia boy's home did investigators -- a lavender aromatherapy spray manufactured in India and sold at Walmart, that hadn't been sampled previously.

"It was a proverbial needle in a haystack, and we found it in that aromatherapy spray bottle," Bower said. "When we found it, we went back to state health departments and asked them to contact the patients. The family in Texas recalled using that type of spray bottle."

Geller noted that CDC, the Georgia Department of Public Health, and the child's parents "worked together to sample dozens of consumer products and natural materials around the house."

"The contribution of his parents -- welcoming investigators into their home and answering questions, even in the setting of grieving the loss of their child -- cannot be overstated," Geller said.

Bower said Walmart was cooperative and immediately pulled the spray -- Better Homes & Gardens Lavender & Chamomile Essential Oil Infused Aromatherapy Room Spray with Gemstones -- from store shelves and stopped shipment of the product from its warehouses. The official recall launched on Oct. 21, 2021.

The facility in India where it was manufactured has been conducting tests to determine the exact source, but hasn't yet found it, Bower said.

He added that there are about two additional cases under investigation that could be part of this outbreak.

"If anybody still has this product, it needs to be returned to Walmart immediately," he said.

Lives Saved

The Georgia boy and the Kansas woman both died from their infections. Geller said melioidosis usually has a 10% to 50% mortality rate.

Geller said melioidosis was the definitive cause of death in the Georgia boy. COVID probably contributed to his death, she said, but it was not the underlying cause.

She stressed that in addition to the ongoing decline in hospital autopsies, there is a parallel "critical nationwide shortage of forensic pathologists." The latter play a vital role in determining cause of death, share information with local public health departments, and help provide closure for families.

"In a case like this, I work to piece together what happened for next of kin so that they may begin to find closure and healing," Geller said.

It never gets easier to perform an autopsy on a child -- something Geller, also the parent of a young child, does a few times every year.

"You think about how he never got to grow up or fall in love or grow old," she said of the Georgia boy. "You think about how much his parents loved him, and how they trusted you to be the last doctor to examine their baby. You let the grief for him and everyone that loved him wash over you, and then you do everything in your power to find the truth for his family."

Geller said the boy's mother, in seeking out her autopsy services, had "hoped there would be something we could learn from his death to protect other children."

"I'm not sure we will ever know how many lives he saved," Geller said about the boy.

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