SPONTANEOUS BACTERIAL PERITONITIS AND CHYLOTHORAX RELATED TO BRUCELLA INFECTION IN A CIRRHOTIC PATIENT Mustafa Güçlü1, Tolga Yakar1 , M Ali Habeoğlu2 Başkent University, Faculty of Medicine, Departments of Gastroenterology1 and Pulmonary Disease2, Adana Teaching and Medical Research Center, Adana, Turkey Brucellosis can affect almost all organ systems in humans. Digestive symptoms have been reported in several series. Brucella infection is a chronic systemic disease, particularly in which there is reticuloendotelial system involvement. It can cause rarely hepatitis, cholecystitis or pancreatitis in the gastrointestinal tractus. Brucella infection can rarely cause spontaneous bacterial peritonitis. Although a variety of clinical presentations and complications involving various organ systems has been reported, peritoneal involvement is a very rare presentation. There has been no reported case of massive chylothorax in a cirrhotic patient due to brucellosis in the literature. This report presents a case of spontaneous bacterial peritonitis and chylothorax caused by Brucella melitensis. Key words: Brucella melitensis, chylothorax, spontaneous bacterial peritonitis Eur J Gen Med 2007; 4(4):201-204 INTRODUCTION CASE Brucellosis, a common widespread A 60 year-old women was admitted to zoonosis, especially in countries of the our hospital with complaints of abdominal Mediterranean region, is a multisystemic pain, weakness, dyspnea, diffuse body infectious disease with a wide range of pain and abdominal distention. She had a clinical symptoms. It is known that Brucella history of cirrhosis for five years. Although infection is a systemic disease, but rarely, there was no history of animal keeping, it may also cause local infections in the eating fresh cheese and milk products were gastrointestinal system (i.e. hepatitis, identified. On physical examination, her body cholecystitis, pancreatitis or colitis) (1-2). temperature was 38.70C, pulse 96/minute, and Brucella infections present in two clinical blood pressure 120/80 mmHg. Pulmonary forms: acute and chronic brucellosis, which examination revealed dullness with decreased may resemble a number of diseases. The most breath sounds and fremitus over the right prominent symptoms of acute brucellosis are lung base. There was 2/6 systolic murmur. fever, chills, headache, backache and myalgia Diffuse dullness suggesting ascites was or arthralgia. Splenomegaly is usually present identified in the abdomen. On X-ray of chest and the liver may be palpable. A variety of we noticed pleural effusion in the medial and clinical presentations and complications of basal zones of the right lung and the shift of brucellosis involving various parts of the mediastinum to left. Diagnostic thoracentesis body have been reported. and paracentesis were performed. Bedside Spontaneous bacterial peritonitis (SBP) inoculation of blood culture bottles were is a serious complication of cirrhosis which performed. is seen in 15-20% of advanced cases. The Laboratory analyses were as follows: most common pathogenic organisms of hemoglobin 9.3 g/dL, white blood cell count SBP are Escherichia coli and Klebsiella 9600/mm3 and platelet count 81000/mm3. pneumonia. Brucella is an extremely rare Abnormal biochemical findings were blood cause of peritonitis. Herein, we report an urea nitrogen: 49 mg/dL, creatinine: 1.45 interesting case of cirrhosis complicated with mg/dL, albumin: 2.7 g/dL, total bilirubin: 2.8 chylothorax and ascites, from both of which mg/dL, direct bilirubin: 2.1 mg/dL, alkaline Brucella melitensis were isolated. phosphatase: 173 IU/L, gama-glutamyl transpeptidase: 123 IU/L. The prothrombin time was 18 seconds (INR: 1.5). Aspartate Correspondence: Mustafa Güçlü aminotransferases, Alanine aminotransferase, E-mail: [email protected] lactic dehydrogenase, serum total cholesterol, 202 Güçlü et al. triglyseride and urinary analysis were DISCUSSION normal. Creatinine clearence was 24 mL/ Defects in the host defense mechanism play minute. Uremia was investigated by the a major role in the pathogenesis of SBP. There nephrologists and attributed to prerenal are frequent infections in cirrhotic patients, azotemia. Erytrocyte sedimentation rate was as their defenses against infectious agents 90 mm/hour and C-reactive protein was 46 are altered, and bactericidal and opsonic mg/L (normal: 0-6 mg/L). activites in the ascites of cirrhotic patients are Ascitic fluid findings were as follows: gross reduced. Although E. coli and K. pneumonia appearance was transparent yellow, leukocytes are the most common etiological organisms, 380 /mm3 (with 65% lymphocytes), LDH: 13 a few unusual organisms such as Yersinia IU/L, triglyceride: 45 mg/dL, total protein: enterocolitica, Listeria monocytogenes and 0.33 gr/dL, albumin 0.22 gr/dL. Serum ascites Brucella melitensis may cause SBP (3-4). albumin gradient (SAAG) was 2.48 gr/dL. The Most cases were associated with chronic liver gross appearence of pleural fluid was milky disease or other underlying conditions such and the characteristics were as transuda. The as continuous ambulatory peritoneal dialysis leukocyte number was 6000/ml and there was (5). Brucellosis is a zoonosis and almost neutrophil dominancy in the pleural fluid. The all infections derive directly or indirectly Acid-fast bacillus (AFB) was negative. The from animal exposure. Human brucellosis is level of triglyceride was 161 mg/dl. In the diagnosed on the basis of epidemiological cytologic investigation of pleural fluid many and clinical findings and bacteriological and polymorphonuclear leukocytes, erythrocytes serological tests. Symptoms of the disease and small amounts of lymphocytes and may mimic many of the diseases and show mesothelial cells were identified. Because of varied manifestations of acute and chronic massive and symptomatic pleural effusion, the infection. Complications of brucellosis fluid was drained by thorax tube. In the sputum sometimes may lead to misdiagnosis. analysis AFB was negative and no culture was Brucellosis exists worldwide especially positive (including tuberculosis). Computed in the Mediterranean basin, the Arabian tomography of thorax did not demonstrate Peninsula, the Indian subcontinent, in parts of any pulmonary parenchymal pathology. The Mexico and Central and South America (6). HCV antibody was positive and the patient Brucellosis is endemic in some parts of our has been followed as cirrhosis for about country, especially in the central Anatolian five years. The hepatitis B virus serology, region. It is a multisystem infection that may autoimmune markers and other etiologies of present with a broad spectrum of clinical cirrhosis were negative. Esophagial varices presentations. The most frequent symptoms and severe portal hypertensive gastropathy are fever, chills or rigors, malaise, generalized were observed during upper GI endoscopy ache, headache and fatigue. Brucella is and abdominal ultrasonography revealed an usually caused by ingestion of unpasteurised atrophic nodular liver, splenomegaly and dairy products or infected raw liver. Once tense ascites with the portal vein thrombosis Brucella coccobacilli are ingested, they enter and cavernous transformation. the lymphatic system via the gastrointestinal Because of the diffuse body pain and fever system. A hematogenous dissemination Brucella agglutination test was performed. ensues and is then followed by colonization Brucella serology showed a positive slide of Brucella in reticuloendothelial cells of test, micro-agglutination titer of 1/1280. On liver, spleen, lymph nodes, bone marrow and the fourth day of admission, gram-negative kidney. Brucella rarely causes infections in coccobacilli were noted in blood culture the gastrointestinal system such as hepatitis, bottles inoculated from both ascites and cholecystitis, colitis and pancreatitis (7-8). pleural effusion and on the sixth day, they SBP due to Brucella is extremely rare (9-10). were identified as Brucella melitensis. The 20 Ten cases of brucella peritonitis are reported, mCi 99mTc-MDP radionuclide scans of whole 3 of which were culture negative. To our body bone were normal. knowledge, this is the 11th reported case Ciprofloxacin (500 mg bid) and rifampin ( of culture-proven SBP caused by Brucella 300 mg a daily) was prescribed for six weeks melitensis in a cirrhotic patient. Our patient for the treatment of Brucellosis. A week later, had not only cirrhosis and SBP caused by the patient’s condition had improved and she Brucella melitensis, but also had massive became afebrile. chylothorax (possibly hepatic hydrothorax) with positive culture for brucella. There has been no reported case of massive chylothorax Spontaneous bacterial peritonitis 203 in a cirrhotic patient due to brucellosis in the Brucella peritonitis is a rare clinical form of literature. brucellosis. It should be considered especially Pleural effusion (>500mL) in a cirrhotic in endemic regions, and appropriate patient without primary cardiac or pulmonary serological and microbiological tests should disease is defined as hepatic hydrothorax be performed to confirm the diagnosis. (HH) (11). Precipitating factors for HH are decreased colloid osmotic pressure due to REFERENCES hypoalbuminemia, increased azygous vein 1. Bauze E, Garcia de la Torre M, Parras F. pressure due to the collaterals between portal Brucella meningitis. Rev Infect Dis 1977; and azygous system, fluid leakage from 9: 810-22 thoracic duct by lymphatic flow, fluid oozing 2. Hall WH. Modern chemotherapy for from abdominal