A case of acute hepatitis due to brucellosis.

To the Editor: Brucellosis is a multisystemic infection that can affect any organ system in the body as well as the liver. Hepatic involvement in brucellosis is not rare and hepatomegaly may be documented in 15 to 20% of cases. However, liver function tests are usually mildly elevated. (1) Here, we report a case of brucellosis with acute hepatitis whose hepatic enzymes were significantly elevated and subsequently returned to normal values with treatment.

A 61-year-old male patient was admitted to our clinic with complaints of fever, chills, cough and dyspnea. His temperature was 39[degrees]C, pulse was 76/min, respiratory rate was 16/min and blood pressure was 110/80 mm Hg. Physical examination revealed yellow sclerae and a hepatomegaly of 1 cm. The laboratory test results revealed a leukocyte count of 7.20 x [10.sup.9]/L, C-reactive protein (CRP) of 13.9 mg/L (N: 0-5 mg/L), and an erythrocyte sedimentation rate (ESR) of 26 mm/h. Serum alanine transferase (ALT) level was 750 U/L, serum aspartate transferase (AST) 445 U/L, serum alkaline phosphatase (ALP) 395 U/L, serum [gamma]-glutamyl transpeptidase (GGT) 289 U/L and total bilirubin concentration was 3.6 mg/dL. The HBsAg, antiHbc IgM, antiHAV IgM, antiHCV, antiCMV IgM, anti-VCA IgM and Gruber Widal tests were negative. The patient had a positive history of fresh cheese ingestion, so a Wright agglutination test was also performed and the titer was found to be positive at 1:160. With these findings, he was diagnosed as having acute hepatitis due to brucellosis. Doxycycline 200 mg/d and streptomycin 1 g/d treatment was started. The fever subsided on the second day of the treatment and the liver function tests started to return to normal values.

Streptomycin treatment was discontinued on the 14th day and thereafter, an elevation of the hepatic enzymes to values of ALT 1,500 U/L, AST 1,140 U/L, ALP 255 U/L and GGT 225 U/L was detected. Since this level of elevation of the hepatic enzymes was not expected in brucellosis, a hepatic ultrasonography and magnetic resonance imaging were performed but revealed no abnormal findings. Autoimmune hepatitis markers were also negative. Finally, liver biopsy was done which demonstrated a mild fibrosis in the portal septal area, mononuclear cell infiltration and piecemal necrosis. We continued doxycycline treatment for 6 weeks. On follow-up, the hepatic enzymes had returned to normal, as had the total leukocyte count, CRP and ESR.

Although hepatic involvement with mild jaundice and slightly elevated levels of bilirubin and hepatic enzymes is not rare in brucellosis, significant elevation of the hepatic enzymes is unusual. In our case, the hepatic enzymes become extremely elevated, and subsequently returned to normal with treatment. Acute hepatitis as the only manifestation of brucellosis has been rarely described and since it is related to high bacterial inoculum size, recurrences in these cases could also be seen. (2,3) The pathologic examination of the liver in brucellosis may reveal a variety of changes, including noncaseating granulomas, suppurative abcess or mononuclear cell infiltration. (1) In our case, a mild fibrosis with mononuclear cell infiltrates was demonstrated on pathologic examination of the liver specimen, which also supports our diagnosis.

As a result, brucellosis should be suspected in cases of acute hepatitis when a more prevelant cause is not detected, especially if there is a history of fresh milk product ingestion.

Sule Sunmez, MD

Department of Pulmonary Diseases

Istanbul Faculty of Medicine

Istanbul University

Istanbul, Turkey

Atahan Cagatay, MD

Asli Karadeniz, MD

Halit Ozsut, MD

Haluk Eraksoy, MD

Semra Calangu, MD

Department of Infectious Diseases and Clinical Microbiology

Istanbul Faculty of Medicine

Istanbul University

Istanbul, Turkey

References

1. Madkour MM. Brucellosis. In: Fauci A, Braunwald E, Isselbacher K, et al (eds). Harrison's Principles of Internal Medicine, 14th Ed. New York, McGraw-Hill, 1998, pp 969-71.

2. Erdem I, Cicekler N, Mert D, et al. A case report of acute hepatitis due to brucellosis. Int J Infect Dis 2005;9:349-350.

3. Ozaras R, Celik A, Demirel A. Acute hepatitis due to brucellosis in a laboratory technician. Eur J Intern Med 2004;15:264.