Brucella Haemorrhagic Pleural Effusion

Copyrlght OERS Journals Ltd 1994 European Respiratory Journal lSSN 0903 - 1936

CASE REPORT

Brucella haemorrhagicpleural effusion

S.A. Papiris, M.A. Maniati, A. Haritou, S.H. Constantopoulos

Brucella haemorrhagic pleural emion. SA Papiris, MA. Maniati, A. Haritou, S.H. Dept of Internal Medicine, Pulmonary Constantopoulos. OERS Journals Ltd1994. Section, University of Ioannina,Ioannina ABSTRACT: BruceUa melitensis (BM) is a rarerespiratory pathogen The lungs 451 10. Greece. are usually &ected in the subacute and chronic course of the disease,when pleurisy, Correspondence: S.A. Papiris. Dept of empyema, hilar adenopathy, pneumonia and lung abscess have been described. PulmonaryMedich, University of Ioannina We present a patient with BM haemorrhagic pleural effusion, with low pH, low Medical School. Ioannina451 10, Greece glucose and positive pleural fluid cultures. Keywords: Bnccelh melitemis,haemor- Brucellosis should be considered in the differential diagnosis of patients with long- hgicpleural effusion, low glucose, low standing pleural effusions of unknown aetiology. pH. Eur Respir J.. 1994, 7, 1369-1370. Received:June 22 1993 Accepted after revisionJanuary 27 1994

Brucellosis, a common infection in Mediterranean coun- I tries, rarely affects the lungs. However pleural effusions, I lymphadenitis and pneumonia have occasionally been described in subacute and chronic brucellosis infection [I]. We report a patient with low glucose, low pH, and haemorrhagic pleural effusion due to Brucella melitensis.

3 Case report A 64 year old male farmer, who was a nonsmoker was admitted to the Pulmonary Department because of pleuritic chest pain in the right hemithorax during the last 15 days, dry cough, mild breathlessness on exertion for the

I last month, weight loss (15 kg) in the last six months, 4 and malaise. On admission the patient appeared well. His temper- fig. 1. - Chest roentgenogramshows moderate pleural effusion on the right side. 1 ature was 36.8"C, blood pressure 120180 rnmHg, heart rate 75 beats-min-1and respiratory rate 20 breathsmin-1. Clinical examination was negative, except for mild dull- Diagnostic thoracentesis was performed and disclosed ness on percussion and reduced breath sounds on aus- haemorrhagic pleural fluid with: haematocrit 7.3%. pH cultation in the right lower hemithorax. 6.93, LDH 740 U-ml-1, and glucose 0.94 mmol-1-1. Other Laboratory results gave the following values: erythre findings were: protein level: 36 g.1-1, and white blood cyte sedimentation rate (ESR) 7 rnm-h-1; white cell count cells 1.05~109.1-1,with 60% neutrophils and 40% lym- 7.4~109-1-1,with 51% neutrophils, 36% lymphocytes, 7% phocytes. Gram stain for common bacterial pathogens monocytes and 6% eosinophils; and platelet count: and Ziehl-Neelsen for acid-fast bacilli were negative, and 363~109.1-l. Ekythrocytes, creatinine, urea nitrogen, pre cytology was also negative for malignancy Pleural bio- thrombin time and liver functions were normal. Other psy performed by Abrarn's needle showed nonspecific findings were: lactate dehydrogenase (LDH) 295 Usml-', chronic inflammation. protein value 77 g-1-1 and glucose 5.43 mmol-1-l. Fibreoptic bronchoscopy was negative. Examination Mantoux reaction was negative to 5 IU of human tuber- of bronchial washings was negative for common bacte- culin purified protein derivative (PPD). Blood gases on rial pathogens, fungi and mycobacteria, and also for room air were arterial carbon dioxide tension (Pao;) 9.7 malignancy. Cultures of pleural fluid 10 days later became kPa, arterial carbon dioxide tension (PacoJ 5.5 kPa, pH positive for BM (by growth on THlO broth). Serological 7.43. Chest radiography revealed an encapsulated pleur- studies of pleural fluid and blood subsequently confiied al effusion in the right hemithorax (fig. 1). Computerized BM infection: rose bengal test 3+; and irnrnunoreaction tomography (CT scanning) did not show concomitant Wright 112560. The final diagnosis was brucella haem- lung disease, except pleural effusion. orrhagic effusion. 1370 S.A. PAPIRIS ET AL.

Streptomycin, 1 g daily i.m., for 2 weeks and oxy- tetracyclin, 2 g daily per os in four separate doses, for 6 weeks achieved complete remission of the disease.

Discussion This report illustrates a rare case of pleural haemorrhagic effusion, with low pH and low glucose, caused by BM. Human infection by bacteria of the genus Brucella results from occupational contact with an infected animal, by ingestion of infected milk, milk products or tissues, or by inhalation [I]. Brucellosis may be asymptomatic with only serological evidence of infection. The manifestations of symptomatic brucellosis may be divided into acute, subacute and chronic brucellosis [2]. The symp Fig. 2. - Computerizedtornograph of the same patient through the toms are often nonspecific and include fever, malaise lower lung fdeds: no additional lung infrltratesare evident. and weight loss, often without physical findings. Worldwide, BM is the most frequent cause of brucellosis. There are great differences in the annual incidence glucose and production of acid by leucocytes, and abnor- of human brucellosis in different countries, mainly de- mal transfer of glucose, carbon dioxide and hydrogen ion pending on the extent of animal brucellosis. The areas across the thickened pleural membrane (fig. 2) [lo]. with the highest prevalence are the Mediterranean coun- Treatment with streptomycin for the first 2 weeks and tries [3], Asia and Central and South America. tetracycline daily for 3-6 weeks has been the most effec- Acute respiratory manifestations from Brucella species tive therapy with fewest relapses [S]. Gentarnycin has are usually rare. However, brucellosis is often a pre been successfully substituted for streptom cin. Experience longed and perplexing illness, and in chronic cases pleurisy, with trimethoprim-sulfamethoxazole h Pbeen encourag- empyema, hilar adenopathy, pneumonia, bronchopneu- ing, with an extremely low relapse rate. monia, nodular lung lesions, lung abscess, peribronchial In conclusion, a serological and bacteriological search and peripheral "infiltration"are encountered [l, 41. Pleural for Brucella melitensisshould be mandatory for any pleur- empyema has, however, been reported on at least 10 al effusion of unknown cause occumng in a rural popu- occasions, three of which had long-term course, where- lation, especially in countries where brucellosis is endemic. as brucella haemorrhagic empyema has been reported only once [4]. References Symptoms of respiratory involvementhave rarely been reported. Nonproductive cough has been described in 1. Greer AE. Pulmonary brucellosis. Dis Chest 1956; 29: 1&33% of cases [5]. In one review of 59 cases, dysp 508-519. noea and pleuritic chest pain were present in six patients 2. Gotuzm E, Carrillo C, Guerra J, Llosa L. An evalua- only. Hoarseness and, rarely, mucopurulent, purulent, tion of diagnostic methods for brucellosis: the value of or haemorrhagic sputum have been noted [6]. bone marrow culture. J Infect Dis 1986; 153: 122-125. Histopathological confirmation of pulmonary brucella 3. Garcia-Rodriquez JA, Garcia-Sanchez JE. Bellido L, infection is rare; proven cases usually present necrotiz- Ortiz de la Tabla V, Bellido Barbero J. Review of pul- ing (caseating) granulomatous inflammation, similar to monary brucellosis: a case report on brucellar pulmonary that seen in chronic tuberculosis [7]. empyema. Diagn MicrobialInfect Dis 1989; 11: 53-60. 4. Mili N, Auckenthaler R, Nicod LP. Chronic Brucella A definitive diagnosis of brucellosis is made by recov- empyema. Chest 1993; 103: 620-621. ering the organism from blood, body fluids or tissue spec- 5. Buchanan TM, Faber LC, Feldman RA. Brucellosis ,in imens [8]. Although blood cultures are often positive in the United States 1960-1972. Medicine 19453: 403-413. acute cases, they usually remain negative in subacute or 6. Weinberg AN. Unusual bacterial pneumonia. In: Hshman chronic cases. Up to six weeks may be necessary to AP, ed. Pulmonary Diseases and Disorders. 2nd edn. grow the organisms on appropriate media. In most New York, McGraw Hill, 1988; pp. 1524-1526. cases, the diagnosis is made by a fourfold rise, or a sin- 7. Fraser RG, Pan? JAP, Pan? PD, Fraser .RS,Genereux gle value of >1: 160, in the agglutination titre [9]. GP. Diagnosis of diseases of the chest. 3rd Edn. Vol. Our patient presented an haemorrhagic effusion with 11. Philiadelphia, WB Saunders. 1989. 8. Young EJ. Human brucellosis. Rev Infect Dis 1983; 5: low pH, low glucose, and positive pleural fluid cultures 821-842. for BM, without gross pus or positive cultures for other 9. Diaz RE, Maravi-Roma E, Riven, A. Comparison of pyogenic micro-organisms. By definition he should, thus, counter imrnunoelectrophoresis with other serological not be considered as having empyema, as had the,patient tests in the diagnosis. Bull WHO 1976; 53: 417424. recently described by MILI et al. [4]. Low glucose and 10. Good JT, Taryle DA, Sahn SA. The pathogenesis of low pH should be attributed to a large number of active low glucose, low pH malignant effusions. AmRev Respir ly metabolizing pathogens in the pleural effusion, use of Dis 1985; 131: 737-741.