University of Alabama at Birmingham

2001 Case #2

Universidad Peruana Cayetano Heredia
 
The following case was seen on the Medicine Service of Cayetano Heredia Hospital in Lima by the 2001 Gorgas Expert Course participants.
Image for 01/26/01History: 72 yo male first presented 3 months earlier with 6 weeks of fever, night sweats and some mild lumbar pain. No radiographic studies were done then. He received two weeks of oral antibiotics with resolution of symptoms but then left the hospital without continuing any medication. 1 month ago the fever and night sweats recurred, along with lumbar pain eventually so severe he was unable to walk. Non-contributory past history.

Epidemiology: Resident of Lima. No TB history or exposure. Non-smoker.

Physical Examination: Temp 38 degrees C, extreme tenderness over lumbar spine. Positive Lasegue's sign. Chest clear. No hepatosplenomegaly.

Labs/X-ray: Hct 32, WBC 8,000 with normal differential. Sedimentation rate 62. Normal alkaline phosphatase, bilirubin, and transaminases. Urine normal with normal renal function. Chest x-ray normal. Lumbar spine films shown in photograph. Blood cultures negative.



University of Alabama at Birmingham

2001 Case #2
Diagnosis and Discussion

Universidad Peruana Cayetano Heredia
 
Diagnosis: Sub-acute brucellosis with spondyloarthritis of the lumbar spine due to Brucella melitensis.
Discussion: The major differential given the fever, night sweats, and these abnormal spine films includes Brucella, TB, and malignancy. Several features of the spine films make the lesions seen diagnostic of brucellar disease: 1) lumbar location; 2) pathognomonic bridging osteophytes between adjacent vertebrae (seen here at 2 levels) simultaneous with the presence of both osteoblastic lesions and loss of bony mass in the same vertebrae; 3) loss of disk space; 4) loss of definition of bone at top of the affected vertebrae.

This patient had a B. melitensis agglutination titre of 1:400 and a positive Rose-Bengal and 2-mercaptoethanol test. His fever resolved and back pain has begun to improve on doxycycline and rifampin which he should continue for 6 weeks.

On further questioning the patient relates that his son works in the Central market in Lima and frequently brings home unpasteurized goat cheese. This is a frequent scenario in Peru and most countries at highest risk of brucellosis with the predominant agent being B. melitensis. Brucellosis due to B. abortus acquired from cattle is increasingly uncommon in the US and other countries. All travellers with fevers of unknown origin should be queried for a history of goat cheese ingestion. B. melitensis is commonest in Mexico, Venezuela, Peru, the Mediterranean countries and several of the Arabic countries of the Middle East.