Atypical Manifestation of Brucellosis

A 49-year-old farmer was hospitalized because of a 3-week history of intermittent fever, fatigue, anorexia, generalized myalgias, and malodorous sweating. A nonpruritic, nonhemorrhagic, maculopapular rash recently had developed on his arms, legs, and trunk. The reddish lesions were less than 1 cm in diameter. There was no history of antibiotic or antipyretic drug therapy, and no abnormalities were found on physical examination.

Results of a complete blood cell count were normal except for hematocrit, 40%; platelet count, 410,000/µL; and erythrocyte sedimentation rate, 35 mm/h. The patient's C-reactive protein level was 24 mg/dL, and the rheumatoid factor test was negative. Biochemical parameters were normal except for alanine aminotransferase and aspartate aminotransferase levels, which were twice the upper normal limit.

An ECG, a chest film, and abdominal and transthoracic heart ultrasonograms showed no abnormalities. A tuberculin skin test was negative, as were serologic tests for syphilis, brucellosis, leptospirosis, rickettsiosis, mycoplasmosis, and toxoplasmosis, as well as for infection with cytomegalovirus, Epstein-Barr virus, herpes simplex virus, HIV, and hepatitis C virus. The patient was immune to hepatitis B. Urinalysis results were normal, and urine and blood cultures were negative for pathogens.

Bone marrow for cultures was obtained on admission, and this proved positive for Brucella melitensis, the strain found in sheep and goats. The patient was given doxycycline (200 mg/d) plus rifampin (900 mg/d) for 6 weeks. The skin lesions disappeared a few days after therapy was initiated. This case was submitted by Drs Haralampos Milionis, Leonidas Christou, and Moses Elisaf of Ioannina, Greece.