Print version ISSN 1413-8670
Braz J Infect Dis vol.14 no.6 Salvador Nov./Dec. 2010
LETTER TO THE EDITOR
Mehmet UluğI; Mustafa Kemal CelenII; Celal AyazII
IMD - Özel Ümit Hospital, Department of Infectious Diseases and Clinic Microbiology, Eskisehir, Turkey
IIMD - Dicle University Medical School, Department of Infectious Diseases and Clinic Microbiology, Diyarbakir, Turkey
LETTER TO EDITOR
Brucellosis is a systemic infectious disease and it is still an important public health problem throughout the world, but especially in the Mediterranean region, including Turkey.1 Skeletal, cardiovascular, genitourinary and hematological manifestations are well-known. Neurobrucellosis, peritonitis, pericarditis, pancytopenia and hepatitis are unusual manifestations of brucellosis.2 Liver involvement is frequent in acute and chronic brucellosis. Usually an increase in transaminase values and a mild hepatosplenomegaly occur; sometimes an acute hepatitis develops, but is rarely the only clinical manifestation of the infection.3 We report a case where hepatitis was the only manifestation of acute brucellosis.
A 33-year-old female patient was admitted to our clinic with complaints of fever, chills, headache, nausea and dark urine. Her temperature was 38.4ºC, pulse was 76/min, respiratory rate was 16/min and blood pressure was 110/80 mmHg. Physical examination revealed yellow sclera and a hepatosplenomegaly of 1 cm. The laboratory test results revealed a leukocyte count of 3.8x109/L, C-reactive protein (CRP) of 26 mg/L, and an erythrocyte sedimentation rate (ESR) of 17 mm/h. Serum alanine transferase (ALT) level was 372 U/L, serum aspartate transferase (AST) 303 U/L, serum alkaline phosphatase 454 U/L, serum γ-glutamyl transpeptidase 192 U/L and total bilirubin concentration was 3.2 mg/dL. The HBs-Ag, anti-HBc IgM, anti-HAV IgM, anti-HCV, anti-CMV IgM, anti-VCA IgM and Gruber Widal tests were negative. The patient had a positive history of fresh cheese ingestion, so a Wright agglutination test was also performed and the titer was found to be positive at 1/320. Abdominal ultrasonography showed moderate hepatosplenomegaly, without any structural or morphological changes. With these findings, she was diagnosed as having acute hepatitis due to brucellosis. Blood cultures had been performed before the antibiotic therapy was started. Doxycycline 200 mg/d and streptomycin 1 g/d treatment were started. The fever subsided on the fourth day of the treatment and blood cultures isolated Brucella spp. on the sixth day of admission. On the second week of the treatment, serum ALT and AST levels had fallen to 72 U/L and 59 U/L, respectively. On follow-up, the hepatic enzymes had returned to normal, as had the total leukocyte count, CRP and ESR.
The clinical manifestation of brucellosis is very broad, ranging from asymptomatic infection to serious debilitating disease. Liver and spleen enlargement with mild non-specific elevation of liver enzyme levels can be detected in approximately 50% of all brucellosis patients.1 On the other hand, all cases with elevated liver enzymes should not be evaluated as liver involvement. Hepatic involvement has been reported in the literature in around 2%-3%.4 While hepatitis is common, it is usually subclinical, and jaundice is rare.1 Lulu et al. 5 reported 40% hepatic involvement in their study, namely 1% clinical hepatitis and 38.5% anicteric hepatitis.
In our case, presentation of acute hepatitis with high levels of liver function tests was thought to be due to the high bacterial inoculum's size. However, this case shows that acute hepatitis may represent the first and the only manifestation of brucellosis. Brucellosis must be considered in the differential diagnosis of acute hepatitis, especially if there is a history of fresh milk product ingestion and life in an endemic region.
1. Gur A, Geyik MF, Dikici B, Nas K, Cevik R, Sarac J et al. Complications of brucellosis in different age groups: a study of 283 cases in southeastern Anatolia of Turkey. Yonsei Med J 2003; 44: 33-44. [ Links ]
2. Celen MK, Ulug M, Ayaz C, Geyik MF, Hosoglu S. Brucellar epididymo-orchitis in southeastern part of Turkey: an 8 year experience. Braz J Infect Dis 2010; 14: 109-15. [ Links ]
3. Losurdo G, Timitilli A, Tasso L, Carli C, Ciuchini F, Adone R et al. Acute hepatitis due to brucella in a 2 year old child. Arch Dis Child 1994; 71: 387. [ Links ]
4. Buzgan T, Karahocagil MK, Irmak H, Baran AI, Karsen H, Evirgen O et al. Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature. Int J Infect Dis 2010; 14: e469-78. [ Links ]
5. Lulu AR, Araj GF, Khateeb MI, Mustafa MY, Yusuf AR, Fenech FF. Human brucellosis in Kuwait: a prospective study of 400 cases. Q J Med 1988; 66: 39-54. [ Links ]
Dr. Mehmet Uluğ
Özel Ümit Hastanesi Enfeksiyon Hastaliklari ve Klinik Mikrobiyoloji Klinigi
Batikent Mah. Gerekli Sok. No: 13
Phone: (0532) 4475756 Fax: 0222 3350970
Submitted on: 06/24/2010
Approved on: 06/24/2010
We declare no conflict of interest.