Brucelloma diagnosis and treatment: Report of two cases

Abstract

Objective: We intend to describe two cases of brucellar liver abscess reviewing their clinical presentation, diagnostic clues, characteristic findings on imaging and special treatment needs. Material and methods: We present clinical and imaging data and review the current medical literature. We report two cases. Case One: 58-year-old man with toxic syndrome and right upper quadrant pain of three weeks of evolution. Case Two: 43-year-old man with fever, weakness and arthralgia of 4 weeks of evolution. Results: Case One: Abnormal laboratory findings were as follows: GGT 80 IU/l, ESR 77 mm, CRP 160 mg/l, and Rose Bengal positive. Wright's agglutination test was found to be positive at 1/160. Abdominal ultrasonography (US) showed a 2 cm per 2.5 cm rounded hypodense area with central calcification that was later confirmed by Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Drainage was performed by open surgical drainage. The patient was also treated with streptomycin (1000 mg/day) and doxycycline (200 mg/day). Case Two: Abnormal laboratory findings were as follows: ESR 98 mm, AST 145 IU/L, ALT 33 IU/L, ALP 127 IU/L, CRP 110 mg/dl, and Rose Bengal positive; Wright’s agglutination test was found to be positive at 1/10 ∗ 6. Blood cultures were positive for Brucella. US showed a liver abscess of 3 cm with central calcification and heterogeneous containing. Drainage by laparotomy was performed and treatment with doxycycline (200 mg/day) and streptomycin (1000 mg/day) as well as in the other case. Both had a good early response, they were discharged with a regime of doxycycline 200 mg/day orally for another two months and had no relapse during a 6-month follow-up. Discussion: The diagnosis of brucellar liver abscess is based on the demonstration of specific antibodies at significant titers or seroconversion, like Wright's seroagglutination ≥ 1/160 or a Coombs' antibrucella test ≥ 1/320 and a pseudotumoral heterogeneous lesion with central calcification visible by US, CT and MRI. Surgical drainage and treatment with streptomycin and doxycycline appear to be the most effective option. Conclusions: Brucellar liver abscess is a very rare complication in brucellosis and is easily diagnosed by clinical suspicion supported by positive serology and characteristic image features visible by US, CT and MRI. Brucellosis is a zoonotic infection that can affect almost any organ. Although hepatic involvement is very common during the course of chronic brucellosis, hepatic abscess is a very rare complication of Brucella infection.