Cryoglobulinemia and cutaneous vasculitis in human brucellosis

Membranoproliferative glomerulonephritis in a patient with chronic brucellosis

Brucellosis is the most common zoonotic disease in Greece, with an endemic distribution and can affect any organ. Infiltration of the renal parenchyma causes acute and chronic interstitial nephritis with granulomas, whereas renal glomeruli are rarely affected. The disease has been sporadically reported, and it causes various histopathologic patterns. Herein, we describe the case of a 39-year-old stock breeder with a history of recurrent episodes of bacteremia caused by Brucella melitensis over a period of 3 years. Two months after the last episode of bacteremia, he presented with mild renal insufficiency, nephrotic range proteinuria, and microscopic hematuria. A renal biopsy revealed membranoproliferative glomerulonephritis with a pattern of focal-segmental nodular sclerosis and moderate tubulointerstitial fibrosis. The patient received antimicrobial and corticosteroid therapy with partial remission of the nephrotic syndrome.

Endovascular treatment of thoracic aortic pseudoaneurysm due to brucellosis: a rare case report

BACKGROUND

Arterial damage is a known complication of brucellosis, but the occurrence of a thoracic aortic pseudoaneurysm secondary to brucellosis has not been previously reported.

CASE PRESENTATION

A 65-year-old Chinese man presented with a pseudoaneurysm in the descending segment of the thoracic aorta that caused symptoms of chest pain and intermittent fever. He was diagnosed with a thoracic aortic pseudoaneurysm secondary to brucellosis based on a positive brucella serology test (standard-tube agglutination test) and imaging examination (computed tomography angiography). Anti-brucellosis treatment and covered stent graft implantation were attempted to eliminate the brucellosis and pseudoaneurysm, respectively, and were ultimately successful, with no symptoms after 6 months of follow-up.

CONCLUSION

Endovascular repair may be effective and safe for treating a thoracic aortic pseudoaneurysm resulting from brucellosis.

A Case of Brucellosis with Recurrent Attacks of Vasculitis

Brucellosis is a zoonosis that affects several organs or systems. Skin involvement is nonspecific and it is reported to range between 0,4 and 17% of the patients with brucellosis. Here, we defined a 36-year-old female patient presented to our clinic with a clinical picture of recurrent attacks of vasculitis due to brucellosis for the first time. Skin involvement and vasculitic lesions as a finding of skin involvement are nonspecific in brucellosis. Therefore, in the regions like Turkey where brucellosis is endemic, brucellosis should be kept in mind necessarily in the differential diagnosis of vasculitis.

Prevalence of positive autoimmune biomarkers in the brucellosis patients

Brucellosis is a chronic infectious disease with articular involvement. Discrimination between brucellosis and rheumatologic disorders is difficult in regions endemic for brucellosis. There are few studies about the rate of positive autoantibodies as rheumatologic biomarkers in brucellosis, and the prevalence is variable. In this study, the rheumatologic tests were studied in brucellosis patients. This cross sectional study was performed in two teaching hospitals in Tehran, Iran. Forty-nine patients with brucella infection and 42 healthy participants were enrolled in this study. Brucellosis was diagnosed on the basis of the clinical symptoms and positive serology for brucellosis. Rheumatic factor (RF) and antinuclear antibodies (ANA) were evaluated in all patients. Cyclic citrullinated peptides antibody (ACPA) and anti-double strand DNA (anti-dsDNA) were checked in all patients and control groups. Out of 49 patients, 15 (30.6 %) were RF positive and 4 (8.2 %) were ANA positive. Anti-dsDNA was concurrently positive with ANA in 1 patient (2 %) but ACPA titer was positive in 8 patients (16.3 %). None of the patients with positive autoantibody biomarkers fulfilled the criteria for rheumatologic disorders. The rate of positive RF in healthy people was significantly lower than patient group (2.4 vs. 30.6 %), but the positiveness rate of other biomarkers did not have significant difference in two groups. Sixty percent of the patients with positive RF and 75 % with positive ACPA had skeletal involvement (P < 0.05). Autoantibody biomarkers can be positive in brucellosis. Rheumatologists should be aware of brucellosis in patients with musculoskeletal involvement and positive autoantibody biomarkers in endemic regions.

Non HCV-related infectious cryoglobulinemia vasculitis: Results from the French nationwide CryoVas survey and systematic review of the literature

In patients with infectious cryoglobulinemia vasculitis (CryoVas) in the absence of hepatitis C virus infection, data on presentation, therapeutic management and outcome are lacking. We conducted a nationwide survey that included patients with HCV-negative CryoVas. We describe here the presentation, therapeutic management and outcome of 18 patients with non-HCV infectious CryoVas and 27 additional patients identified form a systematic review of the literature. We included 18 patients, mean age 57.9±13.5 years. Infectious causes were viral infections in 8 patients [hepatitis B virus (HBV) in 4, and cytomegalovirus, Epstein Barr virus, parvovirus B19 and human immunodeficiency virus in one case each], pyogenic bacterial infection in 6 patients, parasitic infection in 2 patients, and leprosy and candidiasis in one case each. Baseline manifestations were purpura (78%), glomerulonephritis (28%), arthralgia (28%), peripheral neuropathy (22%), skin necrosis (22%), cutaneous ulcers (17%), and myalgia (11%). Cryoglobulinemia was type II in 2/3 of cases. Most cases received specific anti-infectious therapy as first-line therapy, sometimes associated with corticosteroids, achieving sustained remission in the majority of cases. Refractory or relapsing patients, frequently related to HBV infection, showed a complete remission after rituximab in addition to antiviral therapy. In contrast, corticosteroids and/or immunosuppressive agents used in the absence of anti-infectious agents were frequently associated with refractory CryoVas. Viral and pyogenic bacterial infections represent the main causes of non-HCV infectious CryoVas. Antimicrobial therapy is commonly associated with sustained remission. Immunosuppressive agents should be considered only as a second-line option in patients with refractory vasculitis.

Brucella endocarditis in a non-endemic area presenting as pyrexia of unknown origin

A 67-year-old man with type 2 diabetes mellitus and hypertension since 7 years presented with a 3-month history of low-grade fever and malaise. Cardiac auscultation revealed the presence of an ejection systolic murmur in the primary aortic area. Most of the investigations for febrile illness were reported normal. His two-dimensional (2D) echocardiogram revealed a calcified aortic valve with mild aortic stenosis. In view of the prolonged fever and calcified aortic valve with mild aortic stenosis, a transoesophageal echocardiogram was performed, which showed small vegetation noted on right coronary cusp about 2.2 mm with free independent mobility. Blood culture was positive for Brucella spp from all the three venepuncture sites. Medical therapy for brucellosis was given with ciprofloxacin, doxycycline, co-trimoxazole and streptomycin, resulting in complete recovery. Brucella endocarditis is a rare, mostly ignored and missed clinical infection. It requires a high index of clinical suspicion for prompt diagnosis and treatment.

A case of Brucella endocarditis in association with subclavian artery thrombosis

Brucellosis is a common zoonosis, endemic in Mediterranean countries, and caused by bacteria of Brucella genus. Brucellosis is a systemic infection and the clinical presentation varies widely from asymptomatic and mild to severe disease. Cardiovascular complications are extremely rare. We present a case of arterial thrombosis in a previously healthy young patient with Brucella endocarditis. Careful attention must be paid to any sign or symptom of thrombosis in patients affected by brucellosis, regardless of the presence of endocarditis and cardiovascular risk factors.

Mixed cryoglobulinemia with renal failure, cutaneous vasculitis and peritonitis due to Brucella melitensis

Cryoglobulinemia has been described in infectious diseases, but in only three patients with brucellosis. We report a 59-year-old male with Brucella peritonitis with cutaneous vasculitis and renal failure that could be related to mixed cryoglobulinemia. As in cryoglobulinemia associated with other infections, resolution of the disease was obtained with specific antimicrobial therapy.

Immune thrombocytopenia attributed to brucellosis and other mechanisms of Brucella-induced thrombocytopenia

Thrombocytopenia often complicates the course of acute brucellosis, mainly due to bone marrow suppression or hypersplenism. Immune thrombocytopenia is also reported in brucellosis, resulting usually in massive thrombocytopenia, purpura, and spontaneous hemorrhage. We describe a case of acute brucellosis in an 85-year old woman, who presented with fever, purpuric skin lesions, anemia, and rhinorrhagia. The absolute platelet count was 1000/microL. Direct and indirect Coombs tests were positive, and a cold-agglutinin was detected. The patient was diagnosed as suffering from brucellosis on the basis of a strongly positive serologic reaction and was treated with doxycycline, streptomycin, and a short course of corticosteroids, with a rapid rise in platelet number.

Endophlebitis of the leg caused by brucella infection

Brucellosis is hyperendemic in Saudi Arabia where, despite rapid urbanisation, a large segment of the population has a nomadic background and clings to cultural traditions such as the drinking of raw milk. We report here an unusual complication of brucellosis in a microbiology technologist. A 41-year-old male presented with an 8-day history of right ankle pain which, over a 3-day period, extended up to his calf where swelling and tightness developed. The leg symptomatology occurred on a background of fever, seats and rigors. X-ray of the limb was normal but a venogram revealed thrombosis of the deep veins of the right calf. Although his blood culture was negative, he developed high brucella antibody titres. Treatment with anticoagulants combined with a course of doxycycline and rifampin produced a full recovery.

Deep venous thrombosis associated with acute brucellosis--a case report

Vascular complications, including arteries and veins associated with Brucella infection, have rarely been reported. To date, only three cases of deep venous thrombosis (DVT) of the lower extremities associated with brucellosis have been previously reported. The authors describe another case of DVT of the right leg in association with acute Brucella infection. Since infection with Brucella may be asymptomatic, and the manifestations of acute brucellosis are exceedingly nonspecific, and in view of the potential for Brucella to cause unexplained or unusual illness involving almost any organ including blood vessels, the authors' case and those previously reported suggest that brucellosis should be included among the causes and infections taken into account in patients suffering from DVT, particularly in those coming from Brucella-endemic areas.

Complications associated with Brucella melitensis infection: a study of 530 cases

We carried out a prospective study of 530 patients older than 14 years of age with brucellosis. We describe the incidence and clinical features of the focal forms of the disease, analyzing some of the possible factors associated with their appearance. One hundred sixty-nine patients (31.9%) had a focal form or complication. Osteoarticular complications were the most frequent, totaling 113 cases (66%), followed by genitourinary with 18 cases (5.1% of males), hepatic (2.5%), neurologic (1.7%), and heart (1.5%). Nine patients (1.7%) had more than 1 complication. In a multivariate analysis, diagnostic delay greater than 30 days (OR 2.0), ESR > 40 mm/hr (OR 1.9), and levels of alpha-2 globulin > 7.5 g/L (OR 6.8) were statistically significant independent variables associated with the presence of focal forms. Twenty-five patients with complications (14.8%) required surgical treatment. The relapse rate was 3.6% for those patients without complications and 4.1% for patients with focal forms (p > 0.05). However, when therapeutic failure, relapses, and mortality were considered together, the risk of an unfavorable evolution was significantly greater in patients with focal forms (10.6% versus 3.6% in patients without complications; OR 1.9, 95% CI 1.4-7.1, p < 0.005). Given the worse prognosis, knowledge and early diagnosis of the focal forms of B. melitensis infection is especially important.