A young male in endemic area , presented by unexplained FEver & abdominal pain and left pleural effusion

1. Recurrent fever & Abdominal pain
Case Presentation
DR : AbdelRahman A Mokhtar
Professor Internist & Gastroenterologist
Mansoura University
July - 2016

2. History :
Mohammed X :
 14 yrs old .
 2ry school student.
 From Dereen ( Dakahlya )

3. Complaint
 Recurrent fever q 3 to 5 days ,
 Abdominal pain and
 Bouts of diarrhoea.

4. Present history
The patient presented to our clinic in june 2014
The condition started 9 month ago by recurrent attacks of fever ,
abdominal pain , bouts of diarrhoea
Associated with anorexia ,
asthenia and marked
weight loss.

5. Revising his documents
• Abd US March 2014 :
Normal apart from Mild pelvic free fluid .

8. Therapeutic trial :
• Colmiditine……….no response.

13. Another therapeutic trial :
• After a border line tuberculine test :
Anti tuberculous was started
But No response.
So , Shifted to Internal Medicine

14. Examination

15. Physical EXam
• Appears ill.
• Pale.
• Temp : 37.6 c
• Bl pr : 110/70
• Pulse 96/ min
• WT : 63 kgm
Palpable bilateral axillary
and bilateral inguinal LN
looks inflammatory.
Abdomen : diffuse
tenderness but no rigidity
.
Chest : signs of RT
pleural effusion.

16. Work UP :
• Lab : CBC
ANA
anti dsDNA
C3 , C4
LFT
RFT
S amylase & lipase
S. ferritin
TSH
HIV
Serum agg .for brucellosis
Stool A H
• Abdominal US
• CXR

25. To Summarise
• Lab : CBC
ANA -ve
anti dsDNA -ve
C3 , C4 normal
LFT normal
RFT normal
S amylase & lipase high lipase
S. ferritin relatively low
TSH normal
HIV -ve
Serum agg .for brucellosis +ve ( 1/160 & 1/320 )

26. •Should brucellosis
be in our D.D from
the start ????

28. Human brucellosis
María Pía Franco, Maximilian Mulder, Robert H Gilman, Henk L Smits
A renewed scientific interest in human brucellosis has
been fuelled by its recent re-emergence and enhanced surveillance in many
areas of the world, and from its status as a class B bioterrorist agent.
The disease remains the world’s most common bacterial zoonosis, with over half
a million new cases annually and prevalence rates in some countries exceeding
ten cases per 100 000 population.
Despite being endemic in many developing countries,brucellosis remains
underdiagnosed and under-reported.
Furthermore, since brucellosis is an important cause of veterinary morbidity and
mortality,the disease can also cause important economic losses indeveloping
countries
Lancet Infect Dis 2007; 7: 775–86
Lancet Infect Dis 2007; 7: 775–86

29. Expansion of animal industries and urbanization, and the lack of hygienic
measures in animal husbandry and in food handling, as well as consumers‟
preference for fresh dairy goods which may be contaminated, partly account for
Brucellosis remaining a public health hazard.

30. Center for Food Security and
Public Health, Iowa State
Order of pathogenicity to humans:
B. melitensis,
B. suis
B. abortus,
Rarely
B. canis,
and
marine mammal Brucella.

31. Transmission

32. Center for Food Security and
Public Health, Iowa State
So , even if you
did not expose
to animal , the
animal may
come to you

33. Susceptibility
Killed at 600 C in 10 minutes
 Pasteurization of milk .
 Survival is long in
refrigerated milk,
ice creams and cheese.

34. Center for Food Security and
Public Health, Iowa State
Transmission to Humans
• Conjunctiva or broken skin contacting infected
tissues
( Brucella abortus and B. suis infections often )
– Blood, urine, vaginal discharges, aborted fetuses,
placentas
• Ingestion ( Brucella melitensis infection is primarily foodborne )
– Raw milk & unpasteurized dairy products
– Rarely through undercooked meat

35. Center for Food Security and
Public Health, Iowa State
Transmission to Humans
• Inhalation of infectious aerosols
– Pens, stables, slaughter houses
• Inoculation with vaccines
– B. abortus strain 19, RB-51
– B. melitensis Rev-1
– Conjunctival splashes, injection
• Person-to-person transmission is very rare (blood
transfusions, bone marrow transplants, and sexual contact between lab
workers and their spouse)
• Incubation varies
– 5-21 days to three months

38. Human brucellosis has a wide spectrum of clinical
manifestations, earning it a place alongside syphilis and
tuberculosis as one of the “great imitators
Thus to an
unaware
physician, the
clinical
diagnosis
becomes a
challenging one.

39. Review of published reports

41. Other exceptionally rare manifestations
• Including thyroid, splenic and epidural
abscess, pneumonitis, pleurisy or
empyema and uveitis.
Unusual manifestations of brucellosis: a retrospective case series in a
tertiary care Greek university hospital
I. Starakis,1 E.E. Mazokopakis 2 and H. Bassaris 1
EMHJ • Vol. 16 No. 4 • 2010
Eastern Mediterranean Health Journal

47. • Brucella pelvic tubo-ovarian abscess
mimicking a pelvic malignancy.
• Seoud MA1, Kanj SS, Habli M, Araj GF, Khalil
AM.
•
• A 57-y-old woman presented with recurrent abdominal and pelvic pain of 6
months' duration with low-grade fever. A computed tomographic scan
indicated an ovarian tumor. Laparotomy revealed a pelvic abscess. Her
symptoms resolved following surgery and antibiotic therapy. Pathology
revealed an extensive inflammatory process. Tissue culture grew Brucella
sp. The diagnosis and management of this previously undescribed pelvic
tubo-ovarian abscess present a particular challenge
Scand J Infect Dis.
2003;35(4):277-8

48. TAKE HOME MESSAGE
practically every organ and system
of the
human body can be affected in brucellosis — a fact that
underscores the importance of including brucellosis in
the differential diagnosis in areas of endemic disease,
even if clinical features are not entirely compatible.
Unusual manifestations of brucellosis: a retrospective case series in a tertiary care Greek
university hospital
I. Starakis,1 E.E. Mazokopakis 2 and H. Bassaris 1
EMHJ • Vol. 16 No. 4 • 2010
Eastern Mediterranean Health Journal

49. Back to our patient :

50. Management
• Amikacin 1gm daily for 10 days.
• Doxycycline 100mg bid for 6 month.
• Rimactane 300mg 2 caps daily for 6
month.
• Famotidine 40mg BD.

51. Anti brucella was started :
• Clinically , marked improvement by the end
of the first 2 weeks:
• No more fever.
• Regained appetite.
• No more abdominal pain.
• Exam : regressed LN, no signs of pleural
effusion,

52. CXR after 1 month anti brucella

53. Abdominal US
• Shows progressive improvement till
becoming completely normal after 3
month.

54. • So, treatment has been extended for 3
month more ( total 6 month , then stopped ).

55. Follow up : 6 month latter
• The patient presented by another attack of:
• Fever.
• A cute abdominal pain & vomiting .
• CXR…….NAD.
• Abd US : Normal apart from moderate
amount of free fluid in the abdomen and
pelvis.

56. Lab work :
• CBC :
TLC : 6.6
Hgb : 8.7 gm /dl & MCV 78.6
PLt : 355
LFTs : Normal.
RFTs : Normal.
S. Amylase: 403/ 86 U/ml

57. Lab work :
• Ascetic fluid :
Haemorrhagic smears. , no detected
atypical or malignant cells.
ADA : 12.57 ( 6.8 – 18.2 ) U/L

58. Serum Agglutination for brucllosis:
• Abortus : -ve 1/40
• Meltensis : -ve 1/40

59. Treatment
• Considering the patient history:
Antibrucella ttt same regimen was started except
trimethoprim – sulfamethoxazole Ds has been added to
replace Rifampicine .
The patient responded well and discharged after 10 days ,
yet , ttt has been extended for one year , with good
tolerability.

60. Take home message :
• Relapse: is a feature but not resistance ,
so, same regimen can be given but for
extended period.
• Organ based complication is a feature of
the disease.
• Negative serology does not exclude
brucellosis , more direct methods for
diagnosis ( PCR & Culture) are urgently
needed.