Volume 9, Issue 4 (10-2023)
Journal of Research in Applied and Basic Medical Sciences 2023, 9(4): 229-232 |
Back to browse issues page
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Abbasi M A, Rikhtegar E, Keshtkar Rajabi S. A Patient with Brucella with initial Manifestations similar to Crimean Congo Fever. Journal of Research in Applied and Basic Medical Sciences 2023; 9 (4) :229-232
URL: http://ijrabms.umsu.ac.ir/article-1-240-en.html
URL: http://ijrabms.umsu.ac.ir/article-1-240-en.html
Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran , Rikhtegar.e@umsu.ac.ir
Full-Text [PDF 201 kb]
(458 Downloads)
| Abstract (HTML) (1221 Views)
Table 1. Initial and final laboratory tests
Patient received Ribavirin with therapeutic dose plus Apotel injection and then the general status was improved. The leukopenia and thrombocytopenia were normalized and the liver enzymes were decreased (Table 1). CCHF test was negative. Also, the hepatitis B and HIV tests were negative. The patient was discharged with good general health.
After one month, patient was readmitted for fever plus right hip and knee pain, and the brucella IgG was in borderline level (10.36). He received treatment for brucellosis including Amikacin, Doxycycline, and Rifampin. The Wright and Coomb's Wright tests were positive. Liver enzymes were normal (SGOT=49.9 U/L; SGPT=38.1; Alkaline phosphatase=138 IL/L). There was mild anemia (Hemoglobin=9.5). Blood culture was positive for Pseudomonas and urine cultures were negative. The general health was improved and the patient was discharged with administration of Doxycycline 100 mg twice a day, and Rifampin 600 mg once a day.
Discussion
Crimean-Congo hemorrhagic fever is a tick-borne disease, often associated with hemorrhagic manifestations and high case fatality rate of 10 to 50 percent (7, 8). It may respond to Ribavirin but the response by brucellosis is less reported (6). Both infectious causes resemble brucellosis and non-infectious causes may resemble CCHF (9). Especially physicians working in endemic regions should have knowledge of probably longer incubation periods after a tick bite (10). Ayatollahi et al. (11) reported nine CCHF cases from Iran who all of them were negative for brucellosis. But differentiation from each other is not mandatory because both would respond to Ribavirin (12).
Metin et al. reported a case of brucellosis mimicking Crimean-Congo hemorrhagic fever (13). Our patient may be such a case. It means that the reported patient may not be actually a CCHF infection case and even the initial admission may have been due to brucellosis but would respond to Ribavirin. Also Karakeçili et al. also presented a case of brucellosis and Crimean-Congo hemorrhagic fever coinfection in an endemic area (14). Our reported case may also have been a coinfection.
Similar to our patient a 13-year-old boy was reported by Almiş et al. as a case of brucellosis misdiagnosed as Crimean-Congo hemorrhagic fever (15). On the other hand, for negative suspected Crimean-Congo hemorrhagic fever cases in an endemic area subclinical infections with Crimean-Congo hemorrhagic fever virus should not be remembered because Ribavirin would treat both infections (16, 17). Totally, according to the reported case, it should be emphasized that Ribavirin is effective in the treatment of brucellosis.
Acknowledgments
The authors thank the patients for participating in the study.
Conflict of interest
The authors have no conflict of interest in this study.
Funding
No funding was required for the study.
Full-Text: (372 Views)
Introduction
The unusual manifestations of brucellosis as an endemic disease involving multiple organ systems include headache, confusion, acute abdomen, psoas abscess, endocarditis, perinephric mass, insulin resistance, and cauda-equina syndrome (1-3). Ribavirin, a guanosine analog that produces broad-spectrum activity against several RNA and DNA viruses, was firstly discovered by Witkowski et al. in 1972 (4, 5). While initially it was approved only for the management of severe respiratory syncytial virus infection in children, it has been used for the treatment of Lassa fever virus infection, influenza A and B, and other pathogenic germs (4-7).
Ribavirin has been utilized as an antiviral drug for several decades (5). Also there are some reports about efficacy in the treatment of brucellosis (6); this matter is not yet completely established. In this paper we report a patient with such situations that was initially diagnosed and treated for CCHF with partial improvement of symptoms after viral therapy with Ribavirin and readmission for brucellosis and improvement of symptoms after combination therapy for the later diagnosis.
Case Presentation:
A 31-year-old male patient was attended with
intermittent fever and chill plus myalgia, melena, and hematuria since one week ago. He had also generalized abdominal pain and loss of appetite with a body mass index of 19 kg/m². He had a history of ten neonatal deaths of livestock in the last month and also the use of local dairy products. Intermittent diarrhea and constipation were also reported. The fever was in the afternoon. The right hip pain was accompanied with claudication that was improved after three days and then the left foot pain was initiated. In laboratory tests, the liver enzymes were raised and pancytopenia was present (Table 1). The Wright and 2ME-Wright tests were negative, however, the family history was positive for brucellosis (brother).
The unusual manifestations of brucellosis as an endemic disease involving multiple organ systems include headache, confusion, acute abdomen, psoas abscess, endocarditis, perinephric mass, insulin resistance, and cauda-equina syndrome (1-3). Ribavirin, a guanosine analog that produces broad-spectrum activity against several RNA and DNA viruses, was firstly discovered by Witkowski et al. in 1972 (4, 5). While initially it was approved only for the management of severe respiratory syncytial virus infection in children, it has been used for the treatment of Lassa fever virus infection, influenza A and B, and other pathogenic germs (4-7).
Ribavirin has been utilized as an antiviral drug for several decades (5). Also there are some reports about efficacy in the treatment of brucellosis (6); this matter is not yet completely established. In this paper we report a patient with such situations that was initially diagnosed and treated for CCHF with partial improvement of symptoms after viral therapy with Ribavirin and readmission for brucellosis and improvement of symptoms after combination therapy for the later diagnosis.
Case Presentation:
A 31-year-old male patient was attended with
intermittent fever and chill plus myalgia, melena, and hematuria since one week ago. He had also generalized abdominal pain and loss of appetite with a body mass index of 19 kg/m². He had a history of ten neonatal deaths of livestock in the last month and also the use of local dairy products. Intermittent diarrhea and constipation were also reported. The fever was in the afternoon. The right hip pain was accompanied with claudication that was improved after three days and then the left foot pain was initiated. In laboratory tests, the liver enzymes were raised and pancytopenia was present (Table 1). The Wright and 2ME-Wright tests were negative, however, the family history was positive for brucellosis (brother).
Table 1. Initial and final laboratory tests
| Laboratory tests | Initial | Final |
| Leukocyte | 3100 | 10400 |
| Erythrocyte | 5.03 mil | 4.99 mil |
| Hemoglobin | 9.8 | 9.6 |
| Platelet | 110 | 349 |
| Urea | 24 | 34 |
| Creatinine | 1.1 | 0.9 |
| SGOT | 530 | 92 |
| SGPT | 451 | 210 |
| Alkaline Phosphatase | 247 | 282 |
After one month, patient was readmitted for fever plus right hip and knee pain, and the brucella IgG was in borderline level (10.36). He received treatment for brucellosis including Amikacin, Doxycycline, and Rifampin. The Wright and Coomb's Wright tests were positive. Liver enzymes were normal (SGOT=49.9 U/L; SGPT=38.1; Alkaline phosphatase=138 IL/L). There was mild anemia (Hemoglobin=9.5). Blood culture was positive for Pseudomonas and urine cultures were negative. The general health was improved and the patient was discharged with administration of Doxycycline 100 mg twice a day, and Rifampin 600 mg once a day.
Discussion
Crimean-Congo hemorrhagic fever is a tick-borne disease, often associated with hemorrhagic manifestations and high case fatality rate of 10 to 50 percent (7, 8). It may respond to Ribavirin but the response by brucellosis is less reported (6). Both infectious causes resemble brucellosis and non-infectious causes may resemble CCHF (9). Especially physicians working in endemic regions should have knowledge of probably longer incubation periods after a tick bite (10). Ayatollahi et al. (11) reported nine CCHF cases from Iran who all of them were negative for brucellosis. But differentiation from each other is not mandatory because both would respond to Ribavirin (12).
Metin et al. reported a case of brucellosis mimicking Crimean-Congo hemorrhagic fever (13). Our patient may be such a case. It means that the reported patient may not be actually a CCHF infection case and even the initial admission may have been due to brucellosis but would respond to Ribavirin. Also Karakeçili et al. also presented a case of brucellosis and Crimean-Congo hemorrhagic fever coinfection in an endemic area (14). Our reported case may also have been a coinfection.
Similar to our patient a 13-year-old boy was reported by Almiş et al. as a case of brucellosis misdiagnosed as Crimean-Congo hemorrhagic fever (15). On the other hand, for negative suspected Crimean-Congo hemorrhagic fever cases in an endemic area subclinical infections with Crimean-Congo hemorrhagic fever virus should not be remembered because Ribavirin would treat both infections (16, 17). Totally, according to the reported case, it should be emphasized that Ribavirin is effective in the treatment of brucellosis.
Acknowledgments
The authors thank the patients for participating in the study.
Conflict of interest
The authors have no conflict of interest in this study.
Funding
No funding was required for the study.
Type of Study: case report |
Subject:
Special
References
1. Kaya O, Avşar K, Zeynep Akçam F. Unusual manifestations of brucellosis. Arch Med Sci 2011;7(1):173-5. [DOI:10.5114/aoms.2011.20627] [PMID] []
2. Jayakumar RV, Al-Aska AK, Subesinghe N, Wright SG. Unusual presentation of culture positive brucellosis. Postgrad Med J 1988;64(748):118-20. [DOI:10.1136/pgmj.64.748.118] [PMID] []
3. Khorvash F, Keshteli AH, Behjati M, Salehi M, Emami Naeini A. An unusual presentation of brucellosis, involving multiple organ systems, with low agglutinating titers: a case report. J Med Case Rep 2007;1:53. [DOI:10.1186/1752-1947-1-53] [PMID] []
4. Loustaud-Ratti V, Debette-Gratien M, Jacques J, Alain S, Marquet P, Sautereau D, et al. Ribavirin: Past, present and future. World J Hepatol 2016;8(2):123-30. [DOI:10.4254/wjh.v8.i2.123] [PMID] []
5. Thomas E, Ghany MG, Liang TJ. The application and mechanism of action of ribavirin in therapy of hepatitis C. Antivir Chem Chemother 2012;23(1):1-12. [DOI:10.3851/IMP2125] [PMID] []
6. Duygu F, Sari T, Kaya T, Bulut N. Brucellosis in Patients with Crimean-Congo Hemorrhagic Fever. J Arthropod Borne Dis 2017;11(4):463-8. [PMID]
7. Shayan S, Bokaean M, Shahrivar MR, Chinikar S. Crimean-Congo Hemorrhagic Fever. Lab Med 2015;46(3):180-9. [DOI:10.1309/LMN1P2FRZ7BKZSCO] [PMID]
8. Bente DA, Forrester NL, Watts DM, McAuley AJ, Whitehouse CA, Bray M. Crimean-Congo hemorrhagic fever: history, epidemiology, pathogenesis, clinical syndrome and genetic diversity. Antiviral Res 2013;100(1):159-89. [DOI:10.1016/j.antiviral.2013.07.006] [PMID]
9. Kara SS, Kara D, Fettah A. Various clinical conditions can mimic Crimean-Congo hemorrhagic fever in pediatric patients in endemic regions. J Infect Public Health 2016;9(5):626-32. [DOI:10.1016/j.jiph.2016.01.007] [PMID]
10. Kaya A, Engin A, Güven AS, İçağasıoğlu FD, Cevit Ö, Elaldı N, et al. Crimean-Congo hemorrhagic fever disease due to tick bite with very long incubation periods. Int J Infect Dis 2011;15(7):e449-52. [DOI:10.1016/j.ijid.2011.03.007] [PMID]
11. Ayatollahi J, Shahcheraghi SH, Mirjalili M. Report of nine cases of Crimean-Congo haemorrhagic fever From Iran. Niger Med J 2015;56(2):156-9. [DOI:10.4103/0300-1652.153409] [PMID] []
12. Flusin O, Iseni F, Rodrigues R, Paranhos-Baccalà G, Crance JM, Marianneau P, et al. Crimean-Congo hemorrhagic fever: basics for general practitioners. Med Trop (Mars). 2010; 70(5-6):429-38. [Google Scholar]
13. Metin O, Teke TA, Aydin ZG, Kaman A, Oz FN, Bayhan GI, et al. A case of brucellosis mimicking Crimean-Congo hemorrhagic fever. J Infect Public Health. 2015;8(3):302-4. [DOI:10.1016/j.jiph.2014.09.008] [PMID]
14. Karakeçili F, Çıkman A, Akın H, Gülhan B, Özçiçek A. A case of brucellosis and Crimean-Congo hemorrhagic fever coinfection in an endemic area. Mikrobiyol Bul 2016;50(2):322-7. [DOI:10.5578/mb.10821] [PMID]
15. Almiş H, Yakıncı C. A case of brucellosis misdiagnosed as Crimean-Congo hemorrhagic fever. Mikrobiyol Bul 2012;46(3):475-9. [Google Scholar]
16. Tanyel E, Sunbul M, Fletcher TE, Leblebicioglu H. Aetiology of PCR negative suspected Crimean-Congo hemorrhagic fever cases in an endemic area. Pathog Glob Health 2016;110(4-5):173-7. [DOI:10.1080/20477724.2016.1213958] [PMID] []
17. Bodur H, Akinci E, Ascioglu S, Öngürü P, Uyar Y. Subclinical infections with Crimean-Congo hemorrhagic fever virus, Turkey. Emerg Infect Dis 2012;18(4):640-2. [DOI:10.3201/eid1804.111374] [PMID] []
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
Contact Information
Address: Urmia University of Medical Sciences, Jahad Ave., Urmia, I.R. Iran. Post code: 57147-83734. P.O. Box. 1138
Email: ijrabms
gmail.com
rabmsumsu.ac.ir
Tel / Fax: +984431937332/+984432240642
