Severe thrombotic microangiopathy associated with brucellosis: successful treatment with plasmapheresis

Case report: Microangiopathic hemolytic anemia and thrombocytopenia in a child with Brucella infection

Thrombotic thrombocytopenic purpura (TTP) is a diffused microvascular occlusive disorder characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and ischemic organ dysfunction. In addition, this condition has been linked to an absence or dysfunction of ADAMTS13. Although TTP can occur due to various factors, such as bacteria, viruses, autoimmune disorders, drugs, connective tissue conditions, and solid tumors, it is a rare hematological complication associated with brucellosis. We describe the first case of a 9-year-old boy with acquired TTP with undetectable ADAMTS-13 assay secondary to Brucella infection. After initiating antimicrobial therapy, symptoms and laboratory abnormalities improved dramatically, with no recurrence of TTP in subsequent follow-ups.

The Angiopoietin-like protein 4: a promising biomarker to distinguish brucella spondylitis from tuberculous spondylitis

Objective

The Angiopoietin-like protein 4 (ANGPTL-4) has been proved to be a protein associated with multiple inflammatory responses. Nevertheless, whether it contributes to distinguishing brucella spondylitis (BS) from tuberculous spondylitis (TS) remains an open question. Our study aim is to explore the capability of the ANGPTL-4 to differentiating BS from TS.

Materials and method

In our study, 53 patients were screened out according to the criteria precisely in Xinjiang Medical University Affiliated of the First Hospital from 1 January, 2016, to 31 December, 2018. Their clinical data were retrospectively reviewed. All of them underwent pathological biopsy and magnetic resonance imaging examination. All the frozen tissue sections were stained for testing ANGPTL-4.

Result

Among the 53 patients, BS had 26 patients, and TS had 27 patients. There was no significant difference between the baseline (P = 0.682) between the two groups. The positive rate of ANGPTL-4 in TS patients (24/27, 88.89%) was higher than that in BS patients (17/26, 65.83%) (P < 0.05). The incidence of microangiopathy and fibrous connective tissue hyperplasia in patients with BS was distinctly higher than those in the TS (P = 0.001, P = 0.008, respectively). Patients of TS frequently presented more granuloma, caseous necrosis, epithelial-like reaction, interleukin 6 (IL-6), and C-reactive protein (CRP) than those of BS.

Conclusion

Our study provided novel insights into distinguishing BS from TS using the ANGPTL-4 combining with histopathology, which may become new supporting evidence.

Key Points • Brucella spondylitis and tuberculous spondylitis are a significant public health concern and even have prolonged damage, contributing to severe health and economic outcomes in Xinjiang of China. • The granuloma, caseous necrosis, epithelioid reaction, microangiosis, and fibrous connective tissue of pathological tissue might play a critical significance for distinguishing brucella spondylitis from tuberculous spondylitis patients. • ANGPLT-4 may become new supporting evidence identify brucella spondylitis and tuberculous spondylitis which is implicated in inflammation angiogenesis-related disorders.

Brucellosis associated with deep vein thrombosis

Over the past 10 years more than 700 cases of brucellosis have been reported in Kosovo, which is heavily oriented towards agriculture and animal husbandry. Here, brucellosis is still endemic and represents an uncontrolled public health problem. Human brucellosis may present with a broad spectrum of clinical manifestations; among them, vascular complications are uncommon. Hereby we describe the case of a 37-year-old male patient with brucellosis complicated by deep vein thrombosis on his left leg.

Comparative study on infection-induced thrombocytopenia among returned travellers

BACKGROUND

Thrombocytopenia is a frequent finding among ill returned travellers and may be caused by a large number of different conditions, including infectious diseases specific or typical for tropical and subtropical regions. In order to assess the diagnostic significance of thrombocytopenia we investigated a large cohort of returned travellers.

METHODS

This was a comparative study in which data collected on 19,473 returned travellers who consulted the outpatient travel clinic of the the University of Munich Hospital between 1999 and 2009 were analysed. Of these, 732 (3.8%) travellers were diagnosed with thrombocytopenia, and their data were compared with those of the remaining 18,741 travellers with normal platelet counts.

RESULTS

Thrombocytopenia was significantly more frequent among patients with malaria (63%), acute human immunodeficiency virus infection (48%), dengue fever/dengue haemorrhagic fever (DF/DHF; 47%), Epstein-Barr virus infectious mononucleosis (23%), paratyphoid/typhoid fever (14%), and rickettsiosis (12%). Malaria and DF/DHF caused 25% of all cases of thrombocytopenia (platelet count <140,000/μl) and 75% of all cases of severe thrombocytopenia (platelet count <30,000/μl). Sex, age, country of origin, duration and type of travel were not significantly correlated with thrombocytopenia. The most frequent travel destinations were Asia (42%), Africa (33%), and Latin America (14%). Travellers to Sub-Saharan Africa (high risk for malaria) and to South/South-east Asia (high risk for DF/DHF) had the highest relative risk for thrombocytopenia.

CONCLUSION

Platelet count among returned travellers is an essential screening parameter, as thrombocytopenia is highly correlated with important infectious diseases, particularly with malaria and DF/DHF.

Brucellosis in Turkey -- an overview

Although almost a century has gone by since its first description in the country, Turkey has not been able to eradicate brucellosis, which remains a major public health problem. In this review, we give an overview of the epidemiological and epizootic status of brucellosis in Turkey. Although little readily accessible data concerning the epidemiology of brucellosis in Turkey are available, the limited official and published data were analyzed. Despite being endemic in Turkey, brucellosis remains under-diagnosed and under-reported. Adherence to traditional farming practices and lifestyles and the consumption of fresh dairy produce contribute to the high incidence of brucellosis. The successful implementation of a national brucellosis control program requires strong political will, good funding, and collaboration, especially between the public health and veterinary sectors. Primary healthcare workers should always keep the symptoms of acute and chronic brucellosis in mind when treating patients.

Systemic infections mimicking thrombotic thrombocytopenic purpura

The absence of specific diagnostic criteria, the urgency to begin plasma exchange treatment, and the risk for complications from plasma exchange make the initial evaluation of patients with suspected thrombotic thrombocytopenic purpura (TTP) difficult. Systemic infections may mimic the presenting clinical features of TTP. In the Oklahoma TTP-HUS (hemolytic-uremic syndrome) Registry, 1989-2010, 415 consecutive patients have been clinically diagnosed with their first episode of TTP; in 31 (7%) the presenting clinical features were subsequently attributed to a systemic infection. All 31 patients had diagnostic criteria for TTP; 16 (52%) had the complete "pentad" of microangiopathic hemolytic anemia, thrombocytopenia, neurologic abnormalities, renal failure, and fever. Four (16%) of 25 patients who had ADAMTS13 measurements had <10% activity; three patients had a demonstrable ADAMTS13 inhibitor. Compared with 62 patients with severe ADAMTS13 deficiency (<10%) who had no recognized alternative disorders, patients with systemic infections had more frequent fever, coma, renal failure, and the complete "pentad" of clinical features. Seventeen different infectious etiologies were documented. A systematic literature review identified 67 additional patients with a diagnosis of TTP or HUS and also a systemic infection. Among all 98 patients, infections with 41 different bacteria, viruses, and fungi were documented, suggesting that many different systemic infections may mimic the presenting clinical features of TTP. Initial plasma exchange treatment is appropriate in critically ill patients with diagnostic features of TTP, even if a systemic infection is suspected. Continuing evaluation to document a systemic infection is essential to determine the appropriateness of continued plasma exchange.

Microangiopathic Anemia of Acute Brucellosis - is it a True TTP?

Thrombotic thrombocytopenic purpura (TTP) is a severe disease, potentially fatal, if not diagnosed and treated promptly. TTP is clinically characterized by the pentad of thrombocytopenia, Coombs-negative hemolytic anemia, fever, renal abnormalities and neurological disturbances. Advances in recent years have delineated the molecular mechanisms of acquired and hereditary TTP.Many infectious organisms have been reported to be associated with TTP, especially mycoplasma, but few cases of Brucella infection associated with thrombotic microangiopathy have been reported.We describe a young woman who presented with TTP after acute infection with both Brucella melitensis and Brucella abortus. The patient completely recovered following aggressive therapy with plasmapharesis, high-dose corticosteroids and appropriate antimicrobial therapy.Since measurement of ADAMTS13 activity and neutralizing antibodies is now available, and none of the reported cases of brucellosis with thrombotic microangiopathy (including the present report) were tested, for better understanding of this rare association, we recommend this work-up in future cases.

Brucellosis-Induced Autoimmune Hemolytic Anemia Treated with Rituximab

Objective:

To present a case of brucellosis-induced severe autoimmune hemolytic anemia (AIHA) that was refractory to traditional corticosteroid treatment and eventually treated with rituximab apart from antibiotic therapy and to discuss the potential role of rituximab in similar cases of AIHA triggered by an underlying reversible cause.

Case Summary:

A 79-year-old woman was diagnosed with severe AIHA (reticulocyte count 21.5%, hemoglobin 6 g/dL). Initial treatment with prednisone in a regional hospital was not efficacious. Brucellosis was diagnosed by serology; the disease was further complicated by hepatic and splenic granulomatous involvement and sacral bone localization. Due to the severity of AIHA as demonstrated by reticulocyte count and hemoglobin levels, the initial unresponsiveness to corticosteroid therapy, the potential of the underlying infectious cause to relapse along with AIHA, and the localization of the pathogen in a focal site (bone involvement) that could act as a constant AIHA trigger, the patient was treated aggressively with rituximab, apart from the typical antimicrobial therapy.

Discussion:

Brucellosis can induce autoimmunity and mimic primary hematologic diseases. We reviewed reports on the unique forms of Brucella-induced hemolysis available in the literature. Massive hemolysis, though, is rare, and in the case of a pathogen such as brucellosis, one cannot ignore the potential for infection relapse accompanied by hemolysis relapse. Cases refractory to corticosteroids are typically treated with invasive amputative procedures such as splenectomy. However, in cases where an underlying therapeutically reversible cause of infection can be identified, the proven short-term efficacy and safety profile of rituximab can be of significance.

Conclusions:

Novel therapeutic approaches with molecular agents such as rituximab may assist in treatment of considerably severe infectious pathogen-induced autoimmune hemolytic anemia that is refractory to first-line therapy.

Brucellosis mimicking vasculitis in a patient with renal failure and peripheral neuropathy

Very few reports of brucellosis with overt renal failure exist in the literature. The authors report interstitial nephritis and distal sensory-motor polyneuropathy as the presenting features of brucellosis. It is postulated that immunologic hypersensitivity reactions may play a role in the pathogenesis of brucellosis. A brief review on this topic is presented.

Brucellosis complicating chronic non-infectious disorders: diagnostic and therapeutic dilemmas

There is little information in the literature on the clinical progress of brucellosis in patients affected by other non-infectious diseases; however, the infection can often trigger an exacerbation of existing underlying conditions in certain target organs. In this report we present four cases of brucellosis complicating previous diseases, and the difficulties in relation to their diagnosis and treatment. The study involved four patients with the following disorders: polycythaemia vera, pulmonary fibrosis, cirrhosis of the liver and arthritis of the knee. Brucellosis was diagnosed by classical serological and bacteriological methods. The strains involved could be isolated only in three of the four patients: two strains were Brucella abortus biovar 1 and one was Brucella suis biovar 1. Two patients relapsed 10 and 7 months after admission, another presented chronic brucellosis and received various therapy schemes, and one died. Since the best selection of antibiotics and the optimal duration of therapy remain unknown for patients having brucellosis complicated by previous pathologies, these remain at the discretion of the attending physician. Management of our patients was controversial in terms of the selection of antibiotics, duration of treatment and decision regarding surgery.

Thrombotic thrombocytopenic purpura associated with Brucella infection

Thrombotic thrombocytopenic purpura (TTP) is characterized by disseminated thrombotic occlusions located in the microcirculation and a syndrome of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, fever, and renal and neurologic abnormalities. Although several factors such as viral and bacterial pathogens, pancreatitis, drugs, collagen-vascular diseases, cancers, and pregnancy have been reported to be associated with TTP, brucellosis is an exceptional cause of this disorder. We represent a 19-year-old woman applying to our outpatient department with the complaints of headache, fever, sweat, malaise, and jaundice. Clinical signs and laboratory findings were consistent with TTP. Brucella agglutination was found to be 1/320 positive. After the administration of therapeutic plasma exchange, all symptoms and laboratory abnormalities improved dramatically. Antibiotic therapy directed to Brucella infection was initiated and no recurrence of TTP was seen.

A multicenter retrospective study defining the clinical and hematological manifestations of brucellosis and pancytopenia in a large series: Hematological malignancies, the unusual cause of pancytopenia in patients with brucellosis

The aim of the study is to review the clinical manifestations and the hematological findings of brucellosis and pancytopenia, with or without hematological malignancies. The records of 202 patients with brucellosis were evaluated retrospectively. Among these cases of brucellosis seen in a 6 year period between April 1999 and June 2005, 30 patients with pancytopenia were identified. The most common manifestation was fever, followed by weight loss, anorexia, malaise, arthralgia, and hepatosplenomegaly. Bone marrow biopsies revealed hypercellularity or normocellularity. The most common findings in the bone marrow evaluation were histiocytic hemophagocytosis and granulomas. Among all cases, we diagnosed 5 hematological malignancies (1 acute myelogenous leukemia, 2 acute lymphoblastic leukemia, and 2 multiple myeloma) concurrently with brucellosis. The clinical symptoms and findings were similar in patients with and without malignancies. In cases with malignancies, the bone marrow biopsy revealed predominant primary disease involvement. Significant increases in ESR and CRP, severe anemia and thrombocytopenia were observed in patients with malignancies. Peripheral blood counts in patients without malignancies returned to normal after antibiotic treatment for brucellosis. However, pancytopenia in two patients with malignancies did not recover because of primary resistant disease. We conclude that while histiocytic hemophagocytosis may be considered as a major cause of pancytopenia, leukemic infiltration can also be an extreme and unusual cause of pancytopenia in patients in whom brucellosis was concurrently diagnosed with hematological malignancies.

An unusual case of acute brucellosis presenting with Coombs-positive autoimmune hemolytic anemia

Brucellosis can mimic several primary hematological diseases. Mild anemia and leukopenia have been frequently associated with acute brucellosis, but pancytopenia, thrombocytopenia, and hemolysis are less frequently seen. To our knowledge, brucellosis has not previously been described in association with Coombs-positive autoimmune hemolytic anemia. Here, we report a case of acute brucellosis presenting with coombs-positive autoimmune hemolytic anemia. The patient responded well to short-term pulse corticosteroid therapy followed by antibrucellosis treatment. We suggest that Brucella infection may be the probable cause of the immune hemolytic anemia in this patient. Therefore, the differential diagnosis of Coombs-positive autoimmune hemolytic anemia should include brucellosis, especially in areas where the disease is endemic.

Therapeutic plasma exchange for the treatment of thrombotic thrombocytopenic purpura: a retrospective multicenter study

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is a rare disease that is fatal if it is not treated. Therapeutic plasma exchange (TPE) has resulted in excellent remission and survival rates in TTP patients.

MATERIAL AND METHODS

We describe our experience with 52 TTP patients treated with TPE during the past eight years (65% of the patients were females; patient median age=34 years, range: 17-73). TPE was carried out 1-1.5 times plasma volume. Fresh frozen plasma (FFP) or cryosupernatant plasma (CSP) was used as the replacement fluid. TPE was performed daily until normalization of serum LDH and recovery of the platelet count to >150 x 10(9)/dL; TPE was then slowly tapered. Clinical, laboratory data, the number of TPE, other given therapy modalities, treatment outcomes and survival rate were evaluated retrospectively.

RESULTS

Overall response (OR) and complete response (CR) rates were 77% and 60%, respectively. Response was excellent in 82.8% of the patients with primary TTP among whom 74.2% were CR. Additionally, there were statistical differences in terms of CR rate between patients with primary TTP and secondary TTP (74.2% vs. 29.4%; p=0.005). OR and CR rates were 79% and 57.9% in patients on TPE alone and 75.8% and 60.6% in patients on TPE+prednisolone, respectively (p=1 and p=0.8). Additionally, there were no statistical differences in terms of OR and CR rates between patients on TPE with FFP and CSP (p=0.25 and p=0.16, respectively). The presence of fever and the number of TPE were statistically important factors influencing the probability of response in multivariate logistic regression analysis (p<0.01 and p<0.01, respectively). Additionally, in multivariate Cox's regression analysis, the probability of survival was higher in patients who were responsive to treatment compared to patients who were unresponsive (p<0.001).

CONCLUSION

TPE is an effective treatment for primary TTP; however, it may be used as adjunctive therapy for secondary TTP until it is under control. The addition of steroids to TPE had no advantage compared to TPE alone. CSP as replacement fluid is not superior compared to FFP. Fever appears to be a bad prognostic indicator. Therefore, prolonged treatment with TPE may be needed in patients with fever.

Intravenous gamma globulin is effective as an urgent treatment in Brucella-induced severe thrombocytopenic purpura

Severe thrombocytopenia is a rare hematologic manifestation of brucellosis, which can occasionally be associated with bleeding into the skin and from mucosal sites. Prompt recognition of this brucellosis complication and aggressive therapy is vital because the mortality rate associated with bleeding into the central nervous system is high. We report a case of a patient infected with Brucella melitensis who was admitted with a severe case of thrombocytopenic purpura. The patient responded well to intravenous gamma globulin (IVIg) treatment with platelet recovery within 2-3 days. For cases of Brucella-induced thrombocytopenic purpura, IVIg may be administered as an urgent therapy until the microbial therapy takes effect.