Brucellosis is infrequently reported in the United States and is mostly an occupational hazard among workers engaged in livestock raising and processing. It is a systemic infectious disease and can involve the liver in varying ways, ranging from benign subclinical increases in serum aminotransferase levels to ominous chronic suppurative disease. It is endemic in many countries, primarily those of the Mediterranean region. It is usually treated with antibiotics. We present a case of a 37-year-old female who develope

Essrani, Rajesh, MD

Shnitser, Anastasia, MD

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine Brucella melitensis-Induced Transaminitis. Rajesh Essrani MD Lehigh Valley Health Network, rajesh.essrani@lvhn.org Anastasia Shnitser MD Lehigh Valley Health Network, anastasia.shnitser@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine  Part of the Gastroenterology Commons Published In/Presented At Essrani, R., & Shnitser, A. (2021). Brucella melitensis-Induced Transaminitis. Cureus, 13(3), e13656. https://doi.org/10.7759/cureus.13656 This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. Review began  02/17/2021 Review ended  02/26/2021 Published 03/02/2021© Copyright 2021Essrani et al. This is an open accessarticle distributed under the terms of theCreative Commons Attribution LicenseCC-BY 4.0., which permits unrestricteduse, distribution, and reproduction in anymedium, provided the original author andsource are credited.Brucella melitensis-Induced TransaminitisRajesh Essrani  , Anastasia Shnitser 1. Internal Medicine, Lehigh Valley Health Network, Allentown, USA 2. Gastroenterology and Hepatology, LehighValley Health Network, Allentown, USACorresponding author: Rajesh Essrani, raj1_essrani@hotmail.comAbstractBrucellosis is infrequently reported in the United States and is mostly an occupational hazard amongworkers engaged in livestock raising and processing. It is a systemic infectious disease and can involve theliver in varying ways, ranging from benign subclinical increases in serum aminotransferase levels toominous chronic suppurative disease. It is endemic in many countries, primarily those of the Mediterraneanregion. It is usually treated with antibiotics. We present a case of a 37-year-old female who developedBrucella melitensis-induced transaminitis, which improved with proper diagnosis and management.Categories: Gastroenterology, Environmental Health, Epidemiology/Public HealthKeywords: brucella melitensis, transaminitis, travel healthIntroductionBrucellosis is a common zoonotic disease distributed around the world, caused by microorganisms of thegenus Brucella, an intracellular bacterium that widely affects animals and can cause systemic infections inhumans with an acute, subacute, or chronic course [1]. The disease is rare in industrialized countriesbecause of the routine screening of domestic livestock and animal vaccination. Brucellosis is infrequentlyreported in the United States. It results from contact with fluids from infected animals (sheep, cattle, pigs,dogs, rats and goats) or by ingestion of unpasteurized dairy products (soft cheese, ice cream and raw milk)[2]. It mainly presents with insidious onset of fever, night sweats (associated with a strong, peculiar, moldyodor), weight loss, headache, fatigue, abdominal pain, malaise, and can result in variable hepaticmanifestations, ranging from a benign subclinical rise in serum aminotransferase levels to ominous chronicsuppurative disease [3]. It requires a specific diagnosis based on epidemiological analysis and confirmatorylaboratory tests to initiate the appropriate antibiotic treatment.This article was presented as a poster at the American College of Gastroenterology (ACG) Virtual ePosterHall in October 2020.Case PresentationA 37-year-old African American female with no significant past medical history presented to the hospitalwith fever and severe headaches. Her symptoms initially started with generalized myalgia and jointstiffness; they later on progressed into a fever, night sweats and headaches which led her to come for anevaluation. She immigrated from Somalia 10 years prior and has traveled extensively outside of the UnitedStates. She reported no weight loss, sick contact, illicit drug abuse, and personal/family history oftuberculosis. Physical exam on admission was significant for mild right upper quadrant tenderness. Bloodwork revealed white blood cell count 2.53 K/uL (4.00 - 10.80 K/uL), hemoglobin count 10.1 g/dL (12.0 - 15.3g/dL), platelet count 131 K/uL (140 - 400 K/uL), creatinine 0.6 mg/dL (0.5 - 1.0 mg/dL), aspartatetransaminase 113 U/L (10 - 35 U/L), alanine transaminase 77 U/L (10 - 35 U/L), alkaline phosphatase 134 U/L(0 - 153 U/L), and total bilirubin 1.4 mg/dL (0 - 1.2 mg/dL) (Table 1). Cross-sectional imaging of chest,abdomen and pelvis revealed ground-glass opacities in the left upper lung lobe and right colonic wall patchythickening consistent with colitis (Figure 1). She had extensive diagnostic workup including bronchoscopyand lumbar puncture, which was initially unremarkable. Blood culture resulted in Brucella melitensis aftereight days as it is slow growing organism. Additional workup for infectious etiologies such asCytomegalovirus (CMV), Epstein-Barr virus (EBV), Hepatitis A, B, and C, and tick-borne panel was negative.She was evaluated for drug-induced, autoimmune, and metabolic etiologies of her laboratory abnormalities,which were eventually ruled out. She was subsequently diagnosed with Brucella melitensis bacteremia. Initialtreatment included doxycycline and gentamycin with symptomatic improvement. She was discharged homeon rifampin and doxycycline to complete six weeks of therapy. Additional history revealed that the patientdrank camel milk in the United Arab Emirates seven months prior to admission. She followed up as anoutpatient with repeat liver enzymes which normalized after completing antibiotic therapy.1 2 Open Access CaseReport  DOI: 10.7759/cureus.13656How to cite this articleEssrani R, Shnitser A (March 02, 2021) Brucella melitensis-Induced Transaminitis. Cureus 13(3): e13656. DOI 10.7759/cureus.13656Test Patient Result ReferenceWhite Blood Cell count 2.53 K/uL 4.00 - 10.80 K/uLHemoglobin Count 10.1 g/dL 12.0 - 15.3 g/dLPlatelet Count 131 K/uL 140 - 400 K/uLCreatinine 0.6 mg/dL 0.5 - 1.0 mg/dLAspartate Transaminase 113 U/L 10 - 35 U/LAlanine Transaminase 77 U/L 10 - 35 U/LAlkaline Phosphatase 134 U/L 0 - 153 U/LTotal Bilirubin 1.4 mg/dL 0 - 1.2 mg/dLTABLE 1: Blood WorkFIGURE 1: CT abdomen and pelvis showing right colonic wall patchythickening consistent with colitisDiscussionBrucellosis is endemic in countries of the Middle East, the Indian subcontinent, Mediterranean basin,Central Asia, sub-Saharan Africa, China, and parts of Mexico and Central and South America [4,5]. The mostcommon way for transmission to humans is the consumption of infected, unpasteurized animal products,contact of mucous membrane or skin with infected animal tissue (such as miscarriage products or placenta)or infected animal fluids (such as urine, milk, or blood), and inhalation of infected aerosolized particles[2,6,7]. Laboratory workers should be informed about the diagnostic possibility of brucellosis in order toimplement special culture techniques and appropriate precautions. The incubation period is usually two tofour weeks; occasionally, it may be as long as several months. Brucellosis is a systemic disease with a wideclinical spectrum from asymptomatic disease to severe or fatal illness. It mainly presents with insidiousonset of fever, night sweats (associated with a strong, peculiar, moldy odor), weight loss, headache, fatigue,abdominal pain, malaise, and arthralgias. Infective endocarditis, although rare, is the most devastatingcomplication from systemic brucellosis and could require surgical intervention. Physical findings arevariable and nonspecific; splenomegaly, hepatomegaly, and/or lymphadenopathy may be observed.Brucellosis should be suspected in patients with signs and symptoms of fever, malaise, night sweats, andarthralgia in the setting of epidemiologic exposure (consumption of unpasteurized dairy products, animal2021 Essrani et al. Cureus 13(3): e13656. DOI 10.7759/cureus.13656 2 of 3exposure in an endemic area, and/or occupational exposure). A definitive diagnosis may be made by cultureof the organism (from blood, body fluids, or tissue), or ≥ a four-fold rise in Brucella antibody titer betweenacute and convalescent-phase serum specimens obtained ≥two weeks apart [8]. In our case, appropriatehistory, clinical signs/symptoms, diagnostic images, and laboratory findings ruled out other possible causesof acute liver injury, leading to the diagnosis of Brucella melitensis-induced transaminitis. The standardtreatment for brucellosis includes the use of antibiotics with activity in acidic intracellular environments(such as doxycycline and rifampin), use of combination therapy (given high relapse rates withmonotherapy), and prolonged duration of treatment. There are no vaccines for the prevention of brucellosisin humans. Patients should be counseled to wait until the completion of therapy before unprotected sexualcontact, and lactating women should be advised to discontinue breastfeeding until completion of treatment[9].ConclusionsThe clinical presentation of brucellosis can be very imprecise because it can affect any organ system. Itshould be considered in the differential diagnosis of fever and transaminitis for those who live or havevisited endemic areas. We recommend obtaining a careful occupational and travel history of patients whohave transaminitis. It is usually diagnosed with blood culture or antibody titers along with labs like completeblood count and liver function tests. The incubation period is usually two to four weeks; occasionally, it maybe as long as several months as it is very slow to grow compared to Staphylococcus aureus so it is importantto keep this in mind.Additional InformationDisclosuresHuman subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: Incompliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/servicesinfo: All authors have declared that no financial support was received from any organization for thesubmitted work. Financial relationships: All authors have declared that they have no financialrelationships at present or within the previous three years with any organizations that might have aninterest in the submitted work. Other relationships: All authors have declared that there are no otherrelationships or activities that could appear to have influenced the submitted work.References1. Franco MP, Mulder M, Gilman RH, Smits HL: Human brucellosis. Lancet Infect Dis. 2007, 7:775-86.10.1016/S1473-3099(07)70286-42. de Figueiredo P, Ficht TA, Rice-Ficht A, Rossetti CA, Adams LG: Pathogenesis and immunobiology ofbrucellosis: review of Brucella-host interactions. Am J Pathol. 2015, 185:1505-1517.10.1016/j.ajpath.2015.03.0033. Akritidis N, Tzivras M, Delladetsima I, Stefanaki S, Moutsopoulos HM, Pappas G: The liver in brucellosis .Clin Gastroenterol Hepatol. 2007, 5:1109-1112. 10.1016/j.cgh.2006.08.0104. Pappas G, Papadimitriou P, Akritidis N, Christou L, Tsianos EV: The new global map of human brucellosis .Lancet Infect Dis. 2006, 6:91-99. 10.1016/S1473-3099(06)70382-65. Seleem MN, Boyle SM, Sriranganathan N: Brucellosis: a re-emerging zoonosis. Vet Microbiol. 2010, 140:392-398. 10.1016/j.vetmic.2009.06.0216. Franco MP, Mulder M, Gilman RH, Smits HL: Human brucellosis. Lancet Infect Dis. 2007, 7:775-786.10.1016/S1473-3099(07)70286-47. Bosilkovski M, Dimzova M, Grozdanovski K: Natural history of brucellosis in an endemic region in differenttime periods. Acta Clin Croat. 2009, 48:41-46.8. Andonopoulos AP, Asimakopoulos G, Anastasiou E, Bassaris HP: Brucella arthritis. Scand J Rheumatol.1986, 15:377-380. 10.3109/030097486090982079. Tuon FF, Gondolfo RB, Cerchiari N: Human-to-human transmission of Brucella - a systematic review . TropMed Int Health. 2017, 22:539-546. 10.1111/tmi.128562021 Essrani et al. Cureus 13(3): e13656. DOI 10.7759/cureus.13656 3 of 3

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