22 Oct 2020

9/30/20: Brucellosis

PGY2 Hima Namboodiri presented a case of a 48 y/o M with a history of hypertriglyceridemia presents with acute on chronic left back pain.  Patient reports he has had this back pain for the past 3 months.  Reports the pain  radiates to his upper back and bilateral legs and is worse with bending and getting out of a chair.  Despite the pain, he reports he is able to walk and complete his ADLs without difficulty.  One day prior to presentation, the pain acutely worsened, prompting presentation to the ED.  Denies any trauma, weakness, changes in sensation of extremities or bowel/bladder incontinence.  No significant family history  Social history includes growing up in a ranch in Jalisco, Mexico but has lived in the US since 1989. He recently traveled to Santa Barbara.  Denies any tobacco/drug/alcohol use.

Vitals: T 36.8, HR 85, RR 16, BP 141/87, O2 sat 100% RA

Physical Exam significant for normal cardiac and pulm exam, point tenderness in midline lumbar spine but neuro exam normal.

CBC: WBC 5.9> Hb 13.9/Hct 41.6 <Plt 269 (MCV 80.9, RDW 14.2%)

Diff: 63% PMN, 25.8% lymph, 8.3% monocytes, 3.1% eosinophils, and 0.4% basophils

CMP:

Na 142/K 34.6/Cl 99/HCO3 28/BUN 14/Cr 1.04 <Glucose 105

ALP 80>T.protein 8/Albumin 5/AST 24/ALT 40/Tbili 1/Dbili 0.2

Coags: PT 13, INR 1.0

MRI Lumbar Spine done in the ED showed L1-L2 large lobulated T2 hyperintensity of the L1 inferior endplate and L2 superior endplate with surrounding reacting bone marrow changes and adjacent focal T2 hyperintensity of the adjacent disc space.

Infectious workup:

  • BCx initially negative but after 5 days, grew Brucella melitensis in 1/2 bottles
  • Fungal BCx negative
  • UA negative
  • MTB AFB and PCR negative
  • HIV negative
  • Acute hepatitis panel nonreactive
  • Cocci Ab <1:2
  • Q fever IgM and IgG negative
  • Brucella Ab IgG 2.06

Further history elucidated that the patient’s mother-in-law recently returned from Mexico with unpasteurized cheese and both the patient and his wife had eaten some.  The patient’s wife was hospitalized earlier with diagnosis of brucellosis.

Treatment: Patient was initially admitted for bone biopsy but given the delay and the history strongly suggestive of Brucellosis, he was discharged with doxycycline and rifampin.  The patient re-presented to the ED 10 days later with worsening back pain and increased LLE weakness and decreased sensation.  Repeat MRI showed increasing epidural phlegmon indenting the ventral sac.  His antibiotics were switched to IV gentamicin and he was discharged to complete the treatment at home.  3 months post discharge, patient followed up in ID clinic and repeat MRI shows improvement but continued L1-L2 hyperintensity.  6months post discharge, patient had NM bone scan without suggestion of infection.

Teaching points:

  1. DDx for back pain:
    1. Compression fracture
    1. Radiculopathy
    1. Spinal stenosis
    1. Vertebral mets
    1. Infection (diskitis, osteomyelitis, epidural abscess)
      1. Bacteria: Staph aureus, strep, GNR (E.coli, proteus), Crucella
      1. Fungal (Cocci, Blasto)
      1. TB (Pott’s disease)
    1. Inflammatory
      1. Sarcoidosis, psoriatic arthritis, IBD associated, reactive arthritis, ankylosing spondylitis
    1. Visceral disease – nephrolithiasis, pyelonephritis, abd aortic aneurysm
    1. Somatization
  2. Brucella transmission is usually direct or indirect contact with animals or animal products (hint: unpasteurized milk/cheese)
  3. Symptoms of brucellosis include fevers, myalgias, arthralgias, bone/joint involvement and endocarditis (culture negative)
  4. Treatment of brucellosis: Doxycycline + Rifampin + streptomycin or gentamicin

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