Brucellosis

An 11-year-old boy presented with a history of moderate-grade remittent fever for 9 days with mild abdominal pain and occasional loose stools in the first 3 days. He had been started on oral cefixime for possible enteric fever. The loose stools and abdominal pain subsided but fever persisted, along with backache and joint pains. He had no other localizing symptoms. There was no significant past medical or surgical history. He was immunized according to the national immunization schedule. On physical examination, the child was alert. General physical examination was normal. Systemic examination revealed a liver of 2 cm and a spleen of 2 cm; both were soft and nontender. The possibilities of enteric fever, scrub typhus, and malaria were considered. He was hospitalized and started on oral doxycycline and intravenous (IV) ceftriaxone and investigated. His investigations revealed a hemoglobin level of 10.9 g/dL, with a normal total and differential leucocyte count, a platelet count of 90,000/mm3, and an erythrocyte sedimentation rate of 27 mm/h. C-reactive protein (CRP) and peripheral smear were normal. His liver enzymes of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were mildly elevated. Renal function tests were normal. Serology for scrub typhus was negative. Oral doxycycline was stopped. The blood and urine cultures were negative. Chest X-ray was normal. An abdominal ultrasound showed hepatosplenomegaly. Fever persisted even after 3 days of intravenous ceftriaxone, but there were no new clinical findings. Repeat CBC revealed a Hb level of 9.2 g/dL with normal TC/DC and a platelet count of 67,000/cu mm. The Mantoux test was nonreactive, and serology tests for cytomegalovirus (CMV), HIV, Epstein–Barr virus (EBV), and hepatitis A, B, and C were negative. Repeat peripheral blood smear revealed no abnormal or malignant cells. An abdominal CT scan showed hepatosplenomegaly and mild ascites. Echocardiography did not show pericardial effusion or vegetation. Bone marrow aspiration showed normocellular marrow with normoblastic erythropoiesis and normal granulocytic series with no maturation abnormality or hemoparasites. The bone marrow culture by an automated BacT/Alert system grew Brucella melitensis. A diagnosis of brucellosis was made. Ceftriaxone was stopped, and treatment with doxycycline and rifampicin was initiated. Fever subsided after 8 days of treatment after which he was discharged and advised to continue the therapy at home for a total duration of 6 weeks.