Brucella glomerulonephritis: case report and review of the literature.

Abstract: The authors present the case of a 17-year-old shepherd who was diagnosed with diffuse proliferative glomerulonephritis and diffuse tubulointerstitial nephritis during the course of Brucella infection. The pathogenesis and the mechanism of renal involvement in brucellosis is discussed in light of the pertinent literature.

Key Words: Brucella, glomerulonephritis

**********

Brucella is a zoonotic disease with a very wide spectrum of clinical findings. Although osteoarticular complications are the most common, cutaneous, genitourinary, nervous, respiratory, and hematologic system involvements can be encountered during the course of the infection. (1) We report the case of a young man who had glomerulonephritis caused by brucellosis and review the current literature.

Case Report

A 17-year-old young man, who worked as a shepherd, was seen for complaints of hematuria and right flank pain over the previous 3 months. These symptoms were accompanied by nausea, vomiting, and fever. Knee pain and weakness of the lower extremities were also disclosed on detailed questioning. He reported no preceding episode of upper respiratory tract infection or any long-term medication use, and the medical history was noncontributory.

On physical examination, he had a fever of 38.5[degrees]C, conjunctivae were pale, and he had pretibial edema and hepatomegaly (3 cm palpable below the costal margin). Blood pressure was normal. Laboratory analysis yielded a hemoglobin level of 11.9 g/dL, hematocrit of 33.7, erythrocyte sedimentation rate of 85 mm/h, C-reactive protein level of 4.09 mg/dL (0 to 0.8), blood urea nitrogen (BUN) level of 128 mg/dL (18 to 40), creatinine level of 3.6 mg/dL (0.5 to 1.2), alanine aminotransferase level of 68 IU/L (0 to 46), and aspartate aminotransferase level of 52 IU/L (0 to 49). Anti-streptolysin O titer was normal; ANA and anti-dsDNA were negative. Urinalysis was consistent with gross hematuria, and 24-hour urinalysis revealed proteinuria (1,234 mg/d). Abdominal ultrasonography showed normal-sized kidneys with increased parenchymal echogenicity and hepatomegaly. The patient was hospitalized with the diagnosis of acute glomerulonephritis. Echocardiography was unremarkable. Because of the patient's fever, Brucella agglutination test was performed and revealed 1/2,560 positivity. Rose-Bengal test, immunoglobulin (Ig)M, and IgG antibodies were all positive. Complement and immunoglobulin levels were normal. The renal biopsy was relevant, with diffuse tubulointerstitial nephritis and diffuse proliferative glomerulonephritis (Figure, A and B). Direct immunofluorescence staining showed C3 deposition in the glomeruli. He was treated with a combination of rifampicin and doxycycline. He was discharged after resolution of the proteinuria and fever and on normalization of his BUN and creatinine levels.

Discussion

Renal involvement in brucellosis is uncommon, and the pertinent literature mainly comprises anecdotal case reports of different types of nephropathies. (2-7)

[FIGURE OMITTED]

The nephritis in brucellosis is usually classified as three types: acute interstitial nephritis or pyelonephritis during the course of acute infection, chronic involvement with granulomas and caseification necrosis, and renal involvement in association with Brucella endocarditis. (8) Secondary IgA nephropathy concomitant with brucellosis has also been described. (4,5) The underlying pathogenetic mechanisms are either direct invasion of the bacteria (interstitial nephritis) or indirect glomerular involvement caused by the circulating immune complexes (glomerulonephritis). (8,9) In our patient, we believe that both mechanisms played a role in the pathogenesis.

Patients with Brucella glomerulonephritis almost always present with urinary sediment abnormalities, proteinuria, and/or azotemia. (2) In our patient, gross hematuria, proteinuria, and increased BUN levels were detected during the initial laboratory analysis.

Despite the renal biopsy, exact diagnosis is generally established with resolution of the clinical findings after antibiotic treatment for brucellosis. (2-6) In our patient, after 1 month of treatment with rifampicin and doxycycline, the hematuria, proteinuria, and azotemia all resolved. The patient's follow-up has been uneventful since that time.

Conclusion

This case draws attention to a rare clinical scenario--nephritis during the course of brucellosis. Accordingly, Brucella infection should also be ruled out in patients with acute glomerulonephritis of unknown etiology, especially in endemic regions.

References

1. Gur A, Geyik MF, Dikici B, et al. Complications of brucellosis in different age groups: a study of 283 cases in southeastern Anatolia of Turkey. Yonsei Med J 2003;44:33-44.

2. Altiparmak MR, Pamuk GE, Pamuk OM, et al. Brucella glomerulonephritis: review of the literature and report on the first patient with brucellosis and mesangiocapillary glomerulonephritis. Scand J Infect Dis 2002;34:477-480.

3. Haririan A, Ghadiri G, Broumand B. Brucella glomerulonephritis. Nephrol Dial Transplant 1993;8:375-376.

4. Siegelmann N, Abraham AS, Rudensky B, et al. Brucellosis with nephrotic syndrome, nephritis and IgA nephropathy. Postgrad Med J 1992;68:834-836.

5. Nunan TO, Eykyn SJ, Jones NF. Brucellosis with mesangial IgA nephropathy: successful treatment with doxycycline and rifampicin. Br Med J 1984;288:1802.

6. Eugene M, Gauvain JB, Roux C, et al. A case of acute brucellosis with membranous glomerulopathy. Clin Nephrol 1987;28:158-159.

7. Doregatti C, Volpi A, Tarelli LT, et al. Acute glomerulonephritis in human brucellosis. Nephron 1985;41:365-366.

8. Dunea G, Kark RN, Lannigan R, et al. Brucella nephritis. Ann Intern Med 1969;70:783-790.

9. Orte L, Teruel JL, Bellas O, et al. [Brucellosis of the kidney: description of 3 cases]. Rev Clin Esp 1979;152:461-464.

Ihsan Ustun, MD, Levent Ozcakar, MD, Nilufer Arda, MD, Murat Duranay, MD, Emel Bayrak, MD, Kadir Duman, MD, Murat Atabay, MD, Basak Engin Cakal, MD, Kadri Altundag, MD, and Serdar Guler, MD

From the Department of Internal Medicine, Ankara Education and Research Hospital, Ankara, Turkey; the Department of Physical Medicine and Rehabilitation and Department of Medical Oncology, Hacettepe University Medical School, Ankara, Turkey; and Dr. Sami Ulus Children's Hospital, Department of Pathology, Ankara, Turkey.

Reprint requests to Dr. Kadri Altundag, 8181 Fannin St., No. 728, Houston, TX 77054. Email: [e-mail]

Accepted February 1, 2005.

RELATED ARTICLE: Key Points

* Brucella is a zoonotic disease with a very wide spectrum of clinical findings.

* Osteoarticular, cutaneous, genitourinary, nervous, respiratory, and hematologic system involvements can be encountered during the course of the infection.

* The nephritis in brucellosis is usually classified as three types: acute interstitial nephritis or pyelonephritis, chronic involvement with granulomas and caseification necrosis, and the renal involvement in association with Brucella endocarditis.