Decompensated undiagnosed liver disease 2ry to brucellosis Lever involvement in brucellosis : Brucellosis involves the liver in varying ways, ranging from benign subclinical increases in serum aminotransferase levels to chronic suppurative disease

2. 2

3. Hx & Examination

4. ▹ 52 years old male K/C of :
-DM on oral hypoglycemic meds
▹ Patient came through ER C/O :
-Abdominal pain, fever for more than 2 weeks.
▹ And 1 day HX of abdominal distention.

5. Abdomenal pain = the pain was generalized vague in
nature intermittent started 2 weeks earlier not radiated
no food relation relieved with bascopan weak him up
from sleep.
Fever = mostly at night associated with sweating,
documented 38 /38.9 /39 Relived by fifadol
No other associations.

6. ▹ Yellowish discoloration of eye & dark urine
▹ Abdominal distention started the day of admission
noticed by family
▹ Patient have HX of wight loss more than 13 kg in
the last 2 months
▹ NO Hx contact with active pulmonary TB , or other
sick patient
▹ No HX of GI bleeding
▹ No HX of change of LOC
▹ NO similar complain in the past.

7. 7
▹ CVS
▹ Respiratory= mild cough 2-3 times a day
▹ Neurology
▹ Genitourinary/renal
▹ Musculoskeletal = back pain 2 month ago
▹ Psychiatry

8. ▹ Patient K/C of DM on glocophage 2 tabs BID
Fifadol , Panadol and baskopan for pain and fever

9. ▹ Family Hx:
NO HX of
liver disease
of Gi
Malegnancy
▹ Allergy:
NKA
▹ Past surgical
Hx:
▹ appendectomy
10 years ago
9

10. This is 52 years old male K/C of DM S/P appendectomy
Patient came to ER with fever & abdominal pain for 2
weeks abdominal distention started at the day of
admission.
10
Summary:

11. “
11
T: 38.4
BP: 120/61
HR: 94
Spo2: 99% RA
✘ Vitals sign
upon presentation:

12. 12
Patient was laying down on bed GCS:15/15
Patient look pale and fatigued with jaundice.
Chest: equal air entry with normal breath sound.
CVS: s1+s2+0 with NO lower limb edema.
Abdomen: mild tenderness, distended with
-ive fluid thrills -ive shifting dullness.
CNS: NO weakness ,sensory intact.
✘ Physical examination
✘ upon presentation :

13. Labs & imaging

14. HGB: 14.4
MCV: 88
WBC: 3.8
PLT: 67
UREA: 4.4
CREA: 76
NA: 128
K: 4.0
MG: 0.56
T.BILI: 79
D.BILI: 64
ALBUMIN: 33
ALP: 748
ALT: 170
INR: 1.1
APTT: 35
PT: 14.9
CRP= 167
ESR= 30
HIV1/2AB= -IVE
Brucella
serology= +ive
14

15. 15
✘ Tumor marker:
CA 19-9 = 17
PSA = 0.221
CEA= 5.3
HBsAg Result=-ive
HCV Antibody=-ive
AST= 188
GGT= 305
BLOOD CS : GRAM NEGATIVE COCCOBACILLARY, SUGGETIVE
OF BRUCELLA
- Other Liver cirrhosis & leishmania test still bending

16. 16
Findings:
1. Coarse heterogeneous liver parenchyma suggestive of underlying liver
parenchymal disease, for clinical correlation. No obvious focal hepatic lesion
could be seen.
2. Mild splenomegaly and mild ascites.
3. Reactive thick-walled edematous gall bladder likely related to underlying
ascites or liver parenchymal disease. NO gall stones
4. Right renal small nonobstructive stone.

17. 17
Suggestive for early lever cirrhosis with signs of portal hypertension

18. 18
Findings:
The visualized parts of the thyroid gland appear within normal. There is a
cystic lesion located in the subcarinal area measuring about 2.2 x 1 cm. No
enlarged lymph nodes noted in the chest. There is a small hiatus hernia
noted. The vessels are all patent with no evidence of major pulmonary
embolism.
The tracheobronchial tree is patent. Small pleural effusion noted in the left
side.

19. 19
Con..
A large area of consolidation noted in the left lower lobe with air
bronchogram. The right lower lobe atelectatic changes noted.
The included cuts of the upper abdomen shows a large to the amount of
ascites.
A cirrhotic liver is noted with no suspicious liver lesions. The hepatic veins
and portal veins are patent. There is splenomegaly noted.
The visualized bones show no suspicious bony lesions or fractures. The
surrounding soft tissues appear within normal.

20. 20
Ascitic tapping :
No white blood cells
No bacteria seen. Albumin= 3

21. 21
Cirrhotic liver with secondary portal hypertension. No concerning hepatic
lesion. " Gallbladder wall thickening, likely reactive with no gallbladder stone.

22. 22
▹ the histologic findings are consistent with chronic
biliary disease, suggestive of sclerosing cholangitis;
however, drug-induced cholangiopathy should be
clinically excluded.
▹ The presence of lobular activity raises the
possibility of a concomitant infection.
▹ Clinical, serologic, radiologic, and microbiological
correlations are required to establish the underlying
etiology.

23. ▹ ESOPHAGUS : At least 5 cords of large esophageal
varices with high risk stigmata ( red wales and nipple
sign). 9 bands applied and hemosatsis achived.
▹ STOMACH : around 200cc of fresh blood seen.
Moderate portal gastropathy, No gastric ulcer or
mucosal bleeding seen. No fundal varices on
retroflextion.
▹ DOUDENUM : Normal 1st and 2nd part.
23

25. 25

27. Diagnosis:
27

28. “
Lever involvement in
brucellosis :
Brucellosis involves the liver in
varying ways, ranging from benign
subclinical increases in serum
aminotransferase levels to chronic
suppurative disease
28

29. “
▹ Liver involvement in patients
with brucellosis: results of the
Marmara study
29
. This study included 325 brucellosis
patients with significant hepatobiliary
involvement identified with
microbiological analyses from 30
centers between 2000 and 2013.

30. 30

31. 31

32. 32

33. Thanks!
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