A previously healthy 11-year-old female presented with abdominal pain for one month and a fever for 15 days. Her medical history was significant for unexplained weight loss over the past month. She was referred from a tertiary care hospital with reported hepatomegaly (13 cm liver span), moderate splenomegaly (16.6 cm), and right-sided minimal pleural effusion on ultrasonography.
On arrival at our hospital, her temperature was 98 F. She was tachycardic with pulse being 140 bpm, and her arterial blood pressure was 108/66 mmHg. Our physical examination referred to epigastric tenderness, abdominal distension, and hepatosplenomegaly with decreased breath sounds on the right side of the chest. Our laboratory results reported pancytopenia (Hemoglobin 7.9 mg/dl, Platelets 79 x 10E9/L, and WBC 5.5 x 10E9/L). Her peripheral smear showed mild microcytic, hypochromic, anisocytosis, elliptocytes, polychromasia, and dimorphic picture of RBCs and few macrophages. Laboratory testing was otherwise significant for Direct Bilirubin (0.4 mg/dl) and Hypoalbuminemia (2.34 g/dl). Upper GI Endoscopy was completely normal. Anti-tissue transglutaminase Ig A levels, ANA levels, serum ceruloplasmin levels, and 24-h urinary copper levels were all within range. CT scan of the abdomen with contrast showed hepatosplenomegaly, mild ascites, multiple enlarged lymph nodes, and a focal area of narrowing in the sigmoid colon. The right middle lung lobe showed patchy ground-glass haziness with few fibrotic nodules, and mild to moderate right-sided pleural effusion was noted (Figure 1). Due to her abdominal pain, we started her course for IV analgesics, but her condition did not improve. Initial infectious workup was unrevealing, with negative malaria, human deficiency virus, Tuberculin skin test, and negative dengue serology. Thoracentesis showed exudative pleural effusion with inflammatory cells rich in lymphocytes, few mesothelial cells, and foamy macrophages; no malignant cells were seen in the fluid. Pleural fluid direct microscopic examination revealed no presence of tuberculosis bacilli. She became very irritable during the hospital stay and had an episode of fit/delirium/psychosis. In addition to the attack, brain magnetic resonance imaging was done, which reported no abnormality except for minimal meningeal enhancement along the right parietal lobe (Figure 2). Lumbar Puncture was advised, which was refused by the attendant. Systemic lupus erythematosus was suspected due to the occurrence of acute psychotic events, but the anti-ds antibody came out negative. However, Brucella antibody titers, Abortus antibody, and Melitensis antibody were >1:320; this explained the presence of Brucella melitensis. Initially, she was started on Injection Meropenem 1 g for six days. After positive titers, Syrup Doxycycline (50 mg/5 ml) and Syrup Rifampicin (2 g/100 ml) were prescribed for six weeks. The patient was followed up in OPD, and symptoms were improved. Rifampicin 8 ml was further continued for 15 days.